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0072 GROVE STREET - Health
72 Grove Street Hyannis. . P A =. 309 .255074 1 I s� i� II q l fi TOWN OF BAMSTABLE LOCATION 7 2 61t 6 VIF S 1 SEWAGE # VILLAGE 41tT n i7 h ASSESSOR'S MAP & LOTYa? a'5�5-' INSTALLER'S NAME&PHONE NO. 6 L/1 sZ SEPTIC TANK CAPACITY /-570 y LEACHING FACILITY: (type) /AJu��P�y_[( (size) NO.OF BEDROOMS S BMDER OR OWNER s!lG �S PEItMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum.Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by y.) ,� 1.t e � Q-�� � _ �r i ,� : �,r .. ,,, � -c ,,, �, � 9� ���(� w �' w w �� �lW �� 9- ��- Commonwealth of Massachusetts so a Title 5 Official Inspection Form U `II? Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Grove Street Property Address <, Alexandra Nowel =' Owner Owner's Name/ information Is Hyannis ✓ f' required for every MA 02601 3-29-19 page, nny)Tr„wn statc Zip Code Dalb ur iiispeutlun IJi 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�attl u u u r►ni,,,�� Important:When A. Inspector Information �� �y flllingoutforms on the computer, �� use only the tab James D.Sears `�:� JAMES rn key to move your Name of Inspector ;...t cursor-do not �s� ma's Ca ewide Enterprises *' = use the return sk key. Company Name 153 Commercial Street ,n s iliil i VQ Company Address Mash pee MA 02649 City/Town Cod Slate Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification , I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 4-1-19 spector's Signature Dete 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. t5lnsp.doc•rev.7)262018 Title 5 Official Inspecilon Form:Subsurface sewage Disposal system•Page 1 of 18 z a5ed xed dH b6£l 61,02 1,0 JdV Commonwealth of Massachusetts �UV Title 5 Official Inspection Form iSubsurface 3ewayr DibWusal System Form -Nat for Voluntary Ass2sSrhents v 72 Grove Street Property Address Alexandra Nowel Owner Owner's Name information io is Hyannis MA 02601 3-29-19 required for every page. CityTrown State Tip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2: 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15,303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below, Comments; Note:Two units: Tied in to system. The system is a 1500 Gal Tank D Box and four chamber's 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass, Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available, ❑ Y ❑ N ❑ ND (Explain below): t5inSD.doc•rev.712812D18 title 5 Official nspection Form:Subsurface Sewage Disposal System-Page 2 of 18 6 a5ed Y2J dH bVEI. 660Z 60 JdV Commonwealth of Massachusetts Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form •Not for Voluntary Assessments F. 72 Grove Street Property Address Alexandra Nowel Owner Owner's Name information is required for every Hyannis NIA 02601 3-29-19 page. City/Town 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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15,303(1)(b)that the system is not functioning in a mannerwhich will protect public health, safety and the environment: 15insp.doc•rev.MOM Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 3 of 18 t, abed xe:1 dH t7l•:El, 61.0Z 1,0 JdV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurfa ce Sewage Disposal System Form .Not for Voluntary Assessments (� 72 Grove Street Property Address Alexandra Nowel Owner Owner's Name information is required for every Hyannis MA 02601 3-29-19 page. City/Town 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 k 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 cr cesspool t5insp.doc•rev.7126/2018 TIUe 5 Official Inspectlon Form:Subsurface Sewage Disposal System-Page 4 of 112 5 abed xe:1 dH tb 6:£6 6 602 1.0 JdV I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Grove Street Property Address Alexandra Nowel Owner Owner's Name information is required for every Hyannis MA 02601 3-29-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) 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 aI wMaO is less than 6"below invert or available volume is less than 1/2 day flow./FAP111w6 ❑ Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well, ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails,The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ 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 mn sp.doc•rev.7126t2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 0l 1S 9 abed xeJ dH S i:£6 ME 60 Jdy Commonwealth of Massachusetts ,F Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Grove Street Property Address Alexandra Nowel Owner Owner's Name information is Hyannis required for every Y MA 02601 3-29-19 page. City/Town State Zip Code Date of Insp ection 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 nwnar nr nrwr?t^r of any I2r8%System conoidorod a oignificant threat under Dectiun C.0 ui railed 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? ❑ ® 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)[31C CMR 15.302(5)] t5in3p.doc-rev,726/2018 Title 5 Official Inspecfon Form:Subsurface Sewage Disposal System•Page 6 of 18 L abed xeJ dH S 6:£6 6 60Z 60 JdV Commonwealth of Massachusetts Titl e Official Inspection Form Sewage Disposal System Form -Not for Voluntary Assessments 72 Grove Street Property Address Alexandra Nowel Owner Ownel's Name information Is required for every Hyannis MA 02601 3-29-19 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x#of bedrooms): 330 Description: 1500 Gal. Tank D Box and four chamber's. Number of current residents: 0 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2017-3,9000Gals Detail: 2018-11,100Gal's Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5insp.doc rev.7/261'2018 Title S Official Inspection Form;Subsurface Sewage Disposal System•Page 7 of 16 g al5ed xed dH 91,:£6 61.02 1,0 udH I Commonwealth of Massachusetts Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Grove Street Property Address Alexandra Nowel Owner Owner's Name Information is required for every Hyannis MA 02601 3-29-19 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/personslsq.ft„ etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: (Last date of occupancyluse: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.doc•rev.7/26/2018 Title 5 Official Inspedion Form:Subsurface Sewage Dleposal System•Page 8 of 18 6 abed xed dH 96:E1, 660Z 60 Jdf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Grove Street Property Address Alexandra Nowel Owner Owners Name information is required for every Hyannis MA 02601 3-29-19 page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ uverriow cess0ee1 ❑ 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; 2005 Permit # 2005-206. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. 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.): Pipein is 4" PVC SCH -40. t5insp.doc-rev.7126/2010 Title 6 Official Inspection Form:Subsurface Sevraw Disposal System-pages oila r F OL a5ed xe� dH CHI, 61,02 1.0 JdV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Grove Street Property Address Alexandra Nowel Owner Owner's Name information is Hyannis required for everyy MA 02601 3-29-19 page, City/Town State Zip Code Date of Inspection D. System Information (cons.) 6. Septic Tank (locate on site plan): Depth below grade: 101, 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. Precast H-10 Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness a° Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 1810 How were dimensions determined? As built-Tape Sludge Judge 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 at working level.Tank and cover's at 10"below grade.Two inlet tee's w/outlet tee. No sign of leakage or over loading. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18 I abed xed dH bZ:£1 6 i3OZ 1.0 Jd`d Commonwealth of Massachusetts Title 5 Official Inspection Form ([i i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Grove Street Property Address Alexandra Nowel Owner Owner's Name information is Hyannis required for every Y MA 02601 3-29-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle V;aty Qf lact pwmiaingi 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: s ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): r Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/28/20M Title 5 omdal Inspection Form:Subsurface Sewage Dlspasal System•Page ii of is Z 6 abed xed dH t?E:E 6 6 ME 1.0 JdV Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form •Not for Voluntary Assessments F i 72 Grove Street Property Address Alexandra Nowel Owner Owner's Name Information is required for every Hyannis MA 02601 3-29-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping rnntraM (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 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or cut of box, etc.): D Box is 16"x16"-28"below grade w/two lines out. Box is clean and solid w/no sign of over loading or solid Carry over. 151nsp,doc•rev.712612018 Title 5 CMcW Inspection Forth:Subsurface Sewage Disposal System-Page 12 Df 18 £i, abed xed dH 9EE I, 61.02 60 add Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t� 72 Grove Street Property Address Alexandra Nowel Owner Owner's Name information is required for every Hyannis MA 02601 3-29-19 page. CityfTown 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 urdel, bystum Is a candltIonal pass. 11. Soil Absorption System (SAS)(locate on site plan,excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ over-Row cesspool number: ❑ innovative/alternative system Type/name of technology: tSnsp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 16 6 abed xeA dH SH 6 ME 60 JdH Commonwealth of Massachusetts Ti Sewage tle 5Official Inspection Form p System Form -Not for Voluntary Assessments C 72 Grove Street Property Address Alexandra Nowel Owner Owner's Name information is required for every Hyannis MA 02601 3-29-19 page. Cityrrown 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.): Leaching is four infiltrators(11'x36'x10"). Ck area and camera out Iines.No sign of over loading or solid carry over. No sign of holding water. h 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.): 15insp.doc•rev.W2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of'8 S 6 a5ed xe:1 dH 92:E L 61.02 1.0 JdV Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 72 Grove Street Property Address Alexandra Nowel Owner Owners Name infermalion io required for every Hyannis MA 02601 3-29-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5inspAoc rev.7/26/2016 Title 5 Officlal Inspection Form:Subsurface Sewage Disposal System•page 15 of 18 9 6 abed xed dH 9Z:£6 61.0Z 1.0 Jdf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Grove Street Property Address Alexandra Nowell Owner Owner's Name information is required for every Hyannis_ annis MA 02601 3-29-19 — paye. City/Town slat" Lip 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 � I L I a b _ ao ' 3'� y 70 15lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 L i, abed xed dH RE 6 6 60Z 60 Jdy Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �- 72 Grove Street V Property Address Alexandra Nowel Owner Owner's Name information is required for every Hyannis MA 02601 3-29-19 page, City/Town State Zip Code Date of Inspection D. System Information (cunt,) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet 24+ 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: Perk test on file. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Perk test 3-22-05. 24'+To G.W.. Bottom of chamber's at 4'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5in sp.doc rev.7126/2018 Title 5 Dfftdal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 9 6 a5ed xed dH LZ£6 61,02 60 JdV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Grove Street Nroperty Acaress Alexandra Nowel Owner Owner's Name information is required for every Hyannis MA 02601 3-29-19 page. Cilyrrown - 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: TighVHolding 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 t5insp.doc•rev.712812010 Title 5 Dffidal Inspecdon Form;Subsurface Sewage Disposal System-Page 18 of 18 6 6 abed YPJ dH LZ:£6 6 60Z 1.0 JdV No. U✓ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS RpPlicaction Pool *pg;tem Cottgtructiott Permit Application for a Permit to Construct( , j Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Co on nts Location Address or Lot No. `/a Grjv-e, 5171+ ld Owner's Name,Address and Tel.No. tj�sw#/0 0 5 �..g� 3 5 Assessor's Ma / ti �� 7�.c��S y (�� Cki Installer's Name,Address,and Tel.No. 'bg-6a3 -7 Designer's Name,Address and Tel.No. 1!iS rev)>6 CC4sr} Ca, a,CX 7� Type of Building: Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( ) Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 110 � 3 =3330 //�_ gallons per day. Calculated daily flow -gallons. Plan Date V9 °t r G A9 2-1:1P Number of sheets Revision Date Title Size of Septic Tank /Son Type of S.A.S. 4 /.4.eh C r- Se,- Sa P Descri tion of Soil<Se,- L Nature of Repairs or Alterations(Answer when applicable) 5-eC S'e�A is 0-0 S'X4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued Vyis Board of Healt Signed " Date Application Approved by Date Application Disapproved for the following reas_ r Permit No. r Date Issued r _�_ �_ No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 01ppYication for lbigpogal *pgtem Cougtruction Permit Application for a Permit to Construct( , )Repair( )Upgrade(-�Abandon( ) . ❑Complete System ❑Individual C ' nents Location Address or Lot No.�a Grcrve sIrv-ej Owner's Name,Address and Tel.No. �NS 0 1 Assessor's Ma e �'���`'� ✓p`"5 � b Qrn 3 y � � ,1 Installer's Name,Address and Tel.No. 3 -7 Designer's Name,Address and Tel.No. I: 1iiS 13rcn,-6 rc4 52t Cc, 1 Type of Building: - Dwelling ; No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( 0 Cafeteria( ) Other Fixtures . Design.Flow• �( =. 3 UGH/ F gallons per day. Calculated daily flow ' -gallons. Plan Date P) 11 "e Number of sheets Revision Date Title W Size of Septic Tank /_ 00 Type of S.A.S. '-I !). rh �y, a�(. s r,�C I t:✓ t� �t�l� p Description of Soil S e,- Sa. i L c z Nature of Repairs or Alterations(Answer when applicable) 5"P P r - --—``bate last inspected: Agreement: ; The undersigned-agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with,the.provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi= cate of Compliance has been issued by this Board of Heal Signe `� Date -� Application Approved by I�1 //l _ G Date, Application Disapproved for the following reason Permit No. T ,rs Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance. THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by /-1i iS at 7a G,^over i-rimed-/ hip as constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Perm tNed]) '' l/n dated Installer f~1(, Sri Fr f 1��_{ C`c. , y. Designer 5 i^ 1 The issuance of this permit shall n©`t be co"strued as a guarantee that the system 1 f design 1 Date �� I Inspector ^ r - _ _-A 22 No Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migpogar *pgtem Congtruction Permit Permission is hereby granted to Construct( ')Repair( )Upgrade( )Abandon( ) System located at "7 . 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: Con"structio mus be completed within three years of the date of t erm t. Date,_ Approved by :! 10r Inspector r � Town of Barnstable Health Ins p °FTHE Tp� Office Hours ti Regulatory Services 8:30—9:30 Thomas F.Geiler,Director 1:00—2:00 WIMSTABU, = A,�r Public Health Division. Thomas McKean,Director � 200 Main-Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT— SEPTIC QUESTIONNAIRE 1. General Information: Size of Property: o I Address: ,J , ��� Map Parcel Name: �_/�f � Phone #: 2a. How many bedrooms exist at your property now? v 2b. Are you planning to add any bedrooms? If yes, how many? / 2c. How many bedrooms total are proposed at th property(including the amnesty unit)? 2d. Please include a copy of the floor plans for the entire property - showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label . each room clearly on the plans. 3. Is the dwelling connected to public sewer-? YES or NO � Ifieadwelmg is connected to pubhesewer;slap que ?throught#9 below 4. Location of dwelling is INSIDE or OUTSIDE a Zone of Cp tri blic supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 6. Is a disposal works construction permit on file? YES or NO 6a. If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES or- NO Wonditions: m been by a DEP certified inspector within the last two years? YES or NO --------------- ------------------------------------------------------------------=--------- FOR OFFICE USE ONLY � � l��Division h no objection to bedrooms at this property. : Signed: Date: O;/health/wpf les/amnestyapp I vQ V,ag *F �sb� (JNI7 CONE 3�� !'a C �]� � ONS7rdc,z��J �4 L (3, ------------------------ t cls �c � 5 SWEETSER ENGINEERING P.O. BOX 713—SOUTH DENNIS — MASSACHUSETTS 02660 rEL (608) 398-3922 FAX (508) 398-3063 LAND SURVEYING— ENGINEERING —TITLE 5 SEPTIC SYSTEMS SEPTIC DESIGN PROPOSAL PAGE 2 PROPERTY SURVEY AND FLOOR PLAN SKETCH Please fill out this form,including the floor plan sketch, and return to us with the signed proposal and retainer. This information is necessary to properly prepare your Septic System Design. ;r YOU ARE PLANNING AN ADDITION PLEASE INCLUDE THAT INFORMATION ALONG WITH THE FOUNDATION DIMENSIONS AND LOCATION FOR THE NEW ADDITION. Total#of Rooms V Year Round Home Seasonal Home Owner Occupied Rental 1—#Bedrooms A Family Room/Den L' Living Room Dining Room r #Bathrooms Wasler/Dryer Dishwasher Garbage Disposal V Gas Service Town Water In-ground Electric Wires* In-Ground Oil Tank* In-ground Sprinkler* Ll--*" In-ground Gas Pipes* x Please note on sketch where located. Sweetser Engineering assumes no responsibility if in-ground components are damaged during Soil Testings,Inspections, Locations of and/or Installation of New Septic System. Cellar: Full " Partial (Crawl) Slab Wells. Main Use Irrigation Only (please provide location of all wells) PLEASE USE THE SPACE BELOW AND THE BACK OF THIS SHEET TO PROVIDE US WITH A ROUGH SKETCH OF THE EXISTING FLOOR PLAN(ALL FLOORS). Also include any items that should be avoided,IF FEASIBLE,i.e.shrubs, trees,patios,electric lines,tanks,etc. IF YOUARE PLANNINGANADDITION,PLEASEPROVIDE THELOCATIONAND FOUNDATIONDIMENSIONS. @ s K,� a oed Liu R►vn BecQ 4e�1 �w�e V-� r 05-16-2005 02:OOPM FROM SWEETSER ENGINEERING TO 5oe?906304 P.02 sizsroi NOTICE: This Form.Is To Be Used For the Repair Of Famed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, �� �d� , hereby certify that the engineered plan signed by me dated. �concerning the property located at ?1 meets all of the following criteria: This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS-I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site-without a health agent present. • There is no increase in flout-and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen (14)feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimpior method when applicable] Please complete the following: A) Top of Ground Surface Elevation (using GIS information) 90. 0 B) G.W.Elevation +adjustment for high O.W. _ DIFFERENCE BE d B 7' SIGNED DATE. NOTICE Based upon the above information, a repair permit will be issued for bedrooms a� A49aij an the fu�[Q WAOUI Gnpumd septic s stem plans. . s: TOTAL P.02 Town of Barnstable Regulatory Services RAMSrABLK i Thomas F. Geiler,Director 9$ ' Public Health Division fDHtP�� Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: Designer: Installer: I I ►�s Address: Address: 6cP-J-krf - �L,a!`r►-�.a� mod- �5 ; On cS I d.s ! A� r� �`S lj rcvsias issued a permit to install a (date) (installer) septic system at •rm c S�- based on a design drawn by (address) �� (,� _ J dated 319 zlo Is V I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. qS PEA `j�S �u/c 7 " I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State &Local Re lations. Plan revision or certified as-built by designer to follow. . SN OF kASSgcyG �n �,� DUMAS N (Installer's Signature) No.619 GIs 's��`� SANITAW�`N i (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU. Q:Health/Septic/Designer Certification Form a COMMONWEALTH OF MASSACHUSETTS �C EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR o DEPARTMENT OF ENVIRONMENTAL PROTECT) REC - IVED FEB 1 12003 TOVVN OF BARNSTABLE TITLES HEALTH UEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMEN'j.S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION I C�_9- ) % Obrg Property Address: 72Cy/zv��i/Ied �,���Qec) Sag pj�ce-cs 2-5- -f 7¢> Owner's Name: 4 Owner's Address:_,7-Zt3 '! Bate of Inspection: ►2 1713, Z t S 1 2 t o MAP �/ PARCEL ' Name of Insl•e.,-tor: (please print)_� ���!j . �T�.✓� Company Nr:me: �1-- S �Sd/2�/C y ��✓L LOT. - Mailing Address: 1729 /lam Tel-phone Number: -i-0) �3G/qq 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 timt of the inspection. The inspection was performed based on my_ training and experience in the proper function and i„aintrnance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15-Ak'of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signaturq, Date: 12-e19-41 z 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 pf 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the. DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system i ill perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I EAR {{�Perrni�tnumber � �- b p 115 � 5 �� �� � t is J t � '�"+ `� �v � � �� 9�� � � �•' x a �t' DPARTMEtiN-TOFHE�ALTHSETYANwD + r f b ENVIR`ON$MErNTAXL S RV CEPS t' *� "i h� a a � � b :+�c• ^Wc' yr'�$6 rr s + rid ,yam a '-. f5' p{, - .�u .! qw +'� �;•', � . k k, _ � r -�'•S#i -' / -0ck„ 'Y4. -y �„; liar `•,t •I "� ! Health Off c1Pa1 � •, ,� ,F�W h " " eW OW -\ COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFICE OF ENVIR014MENTAL AFFAIR: DEPARTMENT OF ENVIRONMENTAL PROTECT) TITLE 5 OFFICIAL INSPECTION FO11N1—NOT FOR VOLUNi'ARY'ASSESSMEN'1:S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 72�9�i��S;—/�ebi (�jj�j2^�5✓ f lfL�> i�/B/� ��� �/�/I��SCZS $� 7¢> �_ S lIrf• Owner's Name: F Owner's Address: Date ofInspect'son: 12 / 2 tS� I Z t oZ) Name of Insl•ectnr: (please print)_C /�fz-J C Company Ns me: �5719 S —=7x-e- Mailing Address: ?7-9 egcG4 Tel-phone Number: -5�e9 —IS6 96/q - s — B06 z�96 €,ERiIFICATION 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 timt of the inspection.The inspection was performed based on my training and experience in the proper function and t..ainte.nance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.,41 of Title 5(310 CNIR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatur a1 - Date: /2-19--U Z 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 pf 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 ��/C�vv� w-KK.IA,6 p/eOS!Z 5rrc7W-4-1,� r y ****fhis report only describes conditions at the time of inspection and under the conditions of use nt 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 I Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: yZ C/�k6- Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D 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: S�'�f /✓Gl�p Gr/Q/�K�•(/li biz O�iL \he Conditionally Passes: or more system components as described in the"Conditional Pass"section need to be replaced or e system,upon completion of the replacement or repair,as approved by the Board off lealth,will pass' ,no not determined(Y,N,ND) in the for the following statements. If"not determined"please eptic tank is etal and over 20 years old* or the septic tank(whether metal or not)is structurally hibits substantia ' filtration or exfiltration or tank failure is imminent.System will pass inspection if the ek is replaced with a mplying septic tank as approved by the Board of Health. *A metal septic tank will pass insp tion if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 ears old is available. ND explain: Observation of sewage backup or break out igh static water level in the distribution-box due to broken or obstructed pipe(s)or due to a broken,settled or uneven istribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replace obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obs . cted 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: m 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �Z �Xoif TV-- _ f71�✓�l Owner• G/0Ge . Date of Inspection: /2 9 a-L- C. -Further\ion is Required by the Board of Health: Conditions exisstwvhich require further evaluation by the Board of Health in order to determine if the system is failing to protect public heal f 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 pro 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 mars �2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the sy3t in is functioning in a manner that protects the public health,safety and environment: _ Th stem has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water pply or tributary to a surface water supply. — The system has a se ti tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank an AS and the SAS is within 50 feet of a rivate water supply well. P P PP Y _ The system has a septic tank and SAS and heS�SAS is less than 100 feet but 50 feet or more front a private water supply well••. Method used to determirhdistance "This system passes if the well water analysis,performed at a IIkP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free kom 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 fo 3. Other: 3 .Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO N FORM PART A CERTIFICATION(continued) Property Address jdatl- l ,✓,vJ ' Owner: L/pGc Date of Inspection: 12 i q OZ - 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 6Z4 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool KAlo 9- 13 Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. �G 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 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.] 4/0 (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. �bearl e Systems: sidered a large system the system must serve a facility with a design flow of 10,000 god to 15,000 god. You must indicate ither"yes"or"no"to each of the following: (The following criteria as ply to large systems in addition to the criteria above) yes no the system is within 400 feet of a s face drinking water supply the system is within 200 feet of a tributary to a ace drinking water supply _ — the system is located in a nitrogen sensitive area(Interim We (head 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 significa tthreat,or answered "Yes"in Section D above the large system has failed.The owner or operator of any large system cans_-dered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with--,'. 0 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 I - Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: 41141(/66Ct- Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No V Pump g information wa4 provided by the owne occupant,or Board of Health �+ t �Z �sf/��l gdc7'��1 DFi�J/c✓�.•-F��'r/��j _ Were any of the syster�components pumped out in the previous two weeks? Has/the system received normal flows in the previous two week period? ZI �'z Irv�T1o�✓iv/ f zai9m`l ave 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) v Was the facility or dwelling inspected for signs of sewage back up? ✓_ Was the site inspected for signs of break out ? V Were all system.components,0*c4udir the SAS, located on site? e'eV1.111 � ��2' u o�e'�=ta•.� Were the septic-tank manholes uncovered,opened,and the interior of t7tank inspected for the condition of the baff]es or ees,materia f construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner 7(an%�occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ _V Existing information. For example,a plan at the Board of Health. C/t/- 9/✓ �2 ��s f utcT �z j V — 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)] 1 � �/rJ ��-�d2c� ���o.�rPa.✓e Ts� �Ss��s� . r Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE`VAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 7Z 414vte Owner: / Glloc Date of Inspection: 12 -09 - u� FLOW CO,", JTIONS ItI;SIDENTIAL Number of bedrooms(design):__'I . Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 33616Pp Number of current residents: Does residence have a garbage grinder(yes or no): A/U Is laundry on a separate sewage system(yes or no):l1�r/ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): �U Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):— QO lG f Jv l C- 9G�P� Last date of occupancy: 2p�3G S�a �?6F vSC 'Y CONINI ERCIALANDUSTRIAL T;�Es`blishment: Design flow(b ed on 310 CMR 15.203): Rpd Dasis of design flow seats!persons/sgft,etc.): Grease trap present(yes Industrial waste holding tank presen-r(ye or no)-— Non-sanitary waste discharged to the Title 5 s st (yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): .. Pumping Records GENERAL INFORMATION Source of information: ekvCU 1 z-/9 DZ Was system pumped as part of the inspection(yes or no): If yes, volume pumped:4� al Ions--How was quantity pumped determined? �Y1e7jsd/ttr� Reason for pumping: ���GU� -jg,,,•'�-�7,� - TYPE OF SYSTEM -Septic tank,distribution box,soil absorption system Sgle cesspool _✓0verflowcesspool (3�T��-11 77,E ��_����� � ��� —Privy J 9s tq''i''t- _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank —Attach a copy of the DEP approval Other(describe): Approximate a e of al onponents,date ' stalled(Jf o- )and source of information: , 3 Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ Owner: G/d cyst Date of Inspection: /2 9-o Z- BUILDING SEWER(locate on site plan) Depth below grade: y�2(�'✓/2r�n�G/L/I ,l!�Bata( « /�artcktCL-> 6 rt-a d4 �k Materials of construction: t. a-st -iron _40 PVC_other(explain): Distance from private water supply well or suction line/y �°t✓ww�ram- '� +tt,�K�� Conunents(on condition of joints,venting,evidence of leakage,etc.): eti !l�'X��7 6✓oV��rah ot/c�l , Grov SEPT-IC-T7iNI - bcate on site plan) �S�Dv / �4 S r�t,✓� Depth below grade: ��// ��/.21 1���- ��12 v�,�✓� �E,� 1 o� s j�/�,¢Car 7q�,v�ca 1p �J ra Material of construction:_✓concrete metal_fiberglass_polyethylene _other(explain) ZoNL-tz�?L�a�lc If tank is metal list age: is age confirmed by a Certificate of Compliance (yes or no):—(attach a copy of certificate) -- / Dimensions: �- a l� � iJJ�� � LJ ��,O!¢ Sludge depth: /1,7, 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: y- Distance from bottom of scum to bottom of outlet tee or baffle: flow were dimensions determined: �l��lU2�� ��/lli /.✓f�UUTzd� Conunents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of.leakage,etc.): z /NLest--¢`C.�r r/�o.✓/tio ) �yTr�"Gy � 4 �✓ c2iJ®w svor� _)MV- 4 v 5�4z•,mot G�/f2�L6sJ T—tiv"✓ R�j7�/lpvr�f pa O'/ Fi�G6�Ccz��GucsJ vNa.Q Sf7LKq�yJ •�/y7 GawSas� G'4 AS�TRAIP:_(locate on site plan) Depth bdew Material of constructio . concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or ba e: 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 I'OI3 VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAH r C SYSTEM INFORMATION(continued) Property Address: �72�/��✓�Y1 Owner: /pl Date of Inspection:_ 1 2— 19—6'2 — TIGP rorJ-IOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below,grade: Material of construction: Crete 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 alarm and float switches, etc.): \ DISTRIBUTION BOX:�jft-m4st be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal''a�vidence\of solids carryover,any evidence of leakage into or out of box,etc.): w\ PUMP CI I",,ER: (locate on site plan) Pumps in working order(yes o 9.� Alarms in working order(yes or no): ''�a Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -)�4, 4 Owner: 16!1111-� IU Date of Inspection: 12 -/9 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan)e:�eavatiot If SAS;aat-located"plain3Nh T1 PC o� LiG�ui�leaching pits,n �,cv�av�7 ?�/L umber�GfS tvz-s leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: l;;46� Ty,,�� 2 i>✓3 �.d�7x�cdc�S innovative/altemative system Type/name of technology: �� w� f)cac �tycrlotJ Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): ! v CESSPOOLS: 3 (cesspool must be pumped as part'of inspection)(locate on site plan) Number and configuration: /�JT/ �1 7�j'nzx/C�cr� � Depth—top of liquid to inlet invert: Depth of solids layer: /v�rti«nZ_ j,,,IA&G--r •c�t,�K � .,,�,v�er— / ' �f Depth of scum layer: ','•^��r 2+7// ,)- ¢:2°rv,✓c6 Dimensions of cesspool: 2 rr 3- Materials of construction: �c�✓� e-eic Indication of groundwater inflow(yes or no): U Comments(not conditi of soil igns of hydraulic failure,level of po ding,condition of veg tation,etc.): 7'"/7-1 -C I �T/fILL/ PRIVY: (locate on site plan) Materials of conslTueti / Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,.level of ponding,condition of vegetation,ctc.): 9 'Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSLSS TENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C __----------SYSTEM INFORMATION(continued) =I roperty Address: Owner: 9GGroc�4 m Date of Inspection: 12--/9—oL - SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. 2 0 iZq JL Gds X G�_Q c IFT" ZQ t L.L IZ {c A.rz A0 = r 16 10 V Yj � [L w c:Jo-o p�zw p�f �1 c_ eAv t t1 •6—_3 4 3 4-' " ) 10 r - I'z�� 11 0`I I • OFFICIAL,INSPECTION FORM—NOT FOR d'OI.i T.[�T'I�sls�',�:� S1;r�;I,1 r T'�. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7Z 1z'o T Owner: UQGc� Late of Inspection: 12 9-Iv _ SITE EXAAio Slope / Surface water �,o•✓z� Check cellar ChL Shallow wells /2.L ,.c/ �Ll�6t/ ursJ ,t/v/Z•✓r�r�,//�✓rLGf o/�-2C-44yc� Estimated depth to ground water 2Z i feet /9� Please indicate(check)all methods used to determine the high ground water elevation: J va[J 1t� btained from system design plans on record-If checked,date of design plan reviewed: N!/fiObserved site(abutting property/observation hole within 110 feet of SAS) hecked with local Board of Health-explain: / /-a l ��t✓d9`�c f�,1, r� f� t he ked with local excavators, installers-(attachdocumentation,) Accessed USGS database-explain: &J. 5 &17-12 / 7`W�/�T em_ e-V46o You must describhow established the hi h ground water elevation: 14-" , VV ,Uelovv�kY4 I1 0� lw Is _.. ,. ., ...-.,. .. -.,. .. .. .. ...e:. ...,..wn :,. -•,.. ".. .. ..- - � +: .. SST. _. .. . .. .Na .. ..... .. .. sF .. < :.. W141 .. ,,;y,. .M �. a?. Y •,��' .�X.�` .-..ro.>'b. i _.,� :.: _-.BZNCM LARK ^,r ' n T ! !� 20 �T MINIMUM FROM CELLAR SOIL TEST IUH -,J�UN A ON DATE OF SOIL TEST �___�_4 _ = 100.00 10 FT- MINIMUM 10 FT. MINIMUM FROM SLAB OR '�:KAW'L SPACE --� MA Fi 6 2�0 ! ; ELEV. _E ) , ; C-CLEAN SAND S01! T:S' DONE BY FQr�}Eq!�G S M I T I WITNESSED BY ASS CONCRETE NSPECTICMI PORT COVERS 7 - i 4" SCHEDULE 40 PVC PIPE LOAM AND SEED 08SERVA' 1 tf�.E E�tv iT ,. PERCOLATION !�A'E < ' r MIN. P .CH 1/8" P R FT. 1 - -- t 1 1" LAYER OF _� MIN./INCH A' S2 INCHES 1 t j I I 1/8" TO '/2" DEPTH �10R17 TEXTURE COLOR 'v107T. 0Y!iER .� 1 WASHED STONE ~�-- i PI F- '98.90 MAX. � I VENT ! 0-'t � Ap OAMY SAND ' 10YR3/1 NO t ROOTS I 1 4 CAST IRON PE 1 MAX -- 96.65 MIN. I "JOT REQUIRED ; [ #{ k OR EQUAL) MINIMUM I j I ' "-30 ' B _OAMY SAND 10YR5/8 J ROOTS _ -lI-rCH 1/4" PER FT ti r n ! ( 130-132� C COARSE SAND2.5Y7/4 110% COBBLES FLOW UN E ------_j_ __- a' -ELEV, s 97.77� 10" I I MIN. ELEv. _. 99_SOC --',;,,--a o �- LEvEL o 10" 94.57ELEN. _ , _ GAS F = 95.70 - 6" -�N+P `-ELEV. o i E�EV. - --- -- I 4 BAFFLE EL�v 1T ^A' DISTRIB e 30N ELEV. LIQUID.D OUTLET cI I T - ._- � _-.Q��Q_ ! I TTEE (TO BE PLACED ON FIRM BASE) SO (4 1 HIGH CAPACITY iNFk IRA TORS 0!TH STONE z i ! t 4 �EE, 14 INCHES TO BE WATER TESTED i" „ 0.77 ! ✓ AN 11' X 3e',Y 10 " THE NCH FORMA 770/✓ 5 FEE' 19 INCHES 15Q0 GALLON IF MORE THAN ONE OUTLET --- 6 FEET 24 INCHES f i-~- - . WELL p A NO WATER ENCOUNTERED AT 132" ELEV. __BZ80 117 FEET 29 INCHES © '!'A (TO @E PLACED ON FIRM BASE) SOIL ASSORPTIOt 1 ,F y8 FEET 34 INCHES SE�`�C N K 3/4" TO 1 1/2" CLEAN -�'/ S SYSTEM i INDEX f ; (N-20 LOADING), DOUB E W SHE TONE (SAS) ADJUST- FREETI +NS _ ; DESIGN CALCULA 0 dry' c USGS PROBABLE WATER TABLE E�EV. _ ______ NUMBER OF BEDROUMS 3 i SEWAGE DISPOSAL �`.77-M PROe LE OBSERVED WA'E�? TABLE ( / ) E�EV = ______ GARBAGE DISPOSAL UN BC-TOM OF TEST HOLE E,.E V. = -nK- TOTAL ESTIMATED FLOW _ REQUI 0 G L/W/O TANK CAPACITYOL} - GAL,/DAY 5Q- GAL. ACTUTAL SIZE OF SEPTIC TANK ' GAL. i SOIL CLASSIFICATION I DESIGN PERCOLATION RATE $ $__ MIN./IN. EFFLUENT LOADING RATE 0,.74- GAL./DAY/S.F. LEACHING AREA 474.33 SO. FT. (11 X3r6)+(47X2X10/12) M LEACH!NG CAPACITY (AREA X RATE) X!,W GAL./DAY 98 6 .33 X I RESERVE LEACHING CAPACITY % 1,00, GAL./DAY j OT OR 1 W . ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO J.E.P. I TITLE 5 AND THE TOWN'S RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO { WITHIN 6" OF FINISHED GRADE. ± 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN j 10 FT, OF DRIVES OR PARKING AREAS H-20 LOADING SHALL BE I WITHIN 10 FT. OF DRIVES OR PARKING AREAS. USED UNDER OR vWT. f 4. ANY MASONRY UNITS USED TO BRINE; COVERS 10 GRADE SHALL ,- GI 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH I o DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT IS TO t . �9 8.51 C' 6, OBTAIN SUCH, DETERM!NATION FROM APPROPRIATE AUTHORITY. V D 6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR � . O :S TO CALL "DIG-SAFE" AT 1-ti88-•344-7233 AT LEAST 72 HOURS 98.2 PRIOR TO COMMENCING WORK ON SITE. 7, CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS h 98.4 gg 8 99.2 SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE, ANY VARIATION IS TO BE BRCUGHT TO TH'- ATTENTION OF THE DESIGN ENGINEER 1! c,, 98.4 lt,'C` IMMEDIATELY. I 98.3 0 \ 8. PARCEL IS IN FLOOD ZONE _.__.c afl.4 \ 9. LOT IS SHOWN ON ASS-SSORS MAP �M- AS PARCELS 7i 2S3 I SOIL TEST �J 9$•4 Z 10. EXISTING CESSPOOLS ARE TO BE PUMPED AND BAGKFILLED. GARAGE 4 lb 98.5 / 48 4(J' ' !b' 98.4•x, 99.2 I 98.9 -� 9B� -- --------- I � 98.E \ ���/`' ` 9\ 99.2 � � T A• I r IMAS f 99.1 / £CK D. BOX �;1p bt8,V l Q 'sCt GALLON , �� P OWPOI : BOARD OF HEALTH t cFP �T*AN CELLAR Fl / t I o-� FXIS nNG 00ELLfNC ----- ,r �a A TF H 1 / 98.4 4 P�tOI'0 SEPTIC IGN \ q 98.3 I I JA30N T!A.�,ai..�°:NT I i Y I PRGJEc. _OCATION1r 27 & 8 t I } 3�� A � . U u LOT, O r 68-F. JWCUS ! 72 GROVE E STREET, YANNI�S Cy 0 ' 235 GREA i Wi S rERN ROAD !=(`C, IFl• f �, 0. BOX 713 LE-'GGEN - , r ��� 396--3922 SOUTH DENNIS, MASS. 0-266 EXISTING SPOT ELEVATION 04„0 EXISTING CONTOUR ----00----- j CHALKS FINAL SPOT ELEVATION 0 i �ATE -- r FINAL CON70'JFt !�_ A SCALE#`f AP, 2L, 2005 1 � - z ✓ SOIL TEST LOCATION ' d 9.'•50' } -- i UTILITY POLE r _ -1 TOWNCATCHWA EN -W v,- - \\ / l�'� `7� -JSr -._ �J08 N0. 6 54 • ;, I ?v I I GAS UNE CESSPOOL -- I CLEAN^''T -er J `,�,�N • ,�.,� �, REVISED -- SHF' Y 0 L_GS �W 'SER L,NGINEERING r;