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HomeMy WebLinkAbout0063 HOMEPORT DRIVE - Health 63 Homeport Drive A:== 268 - 139 a a ° 9 '�9 0 ° ° ^ ° 90 o o a c ° o ° ' e i w ° u r Commonwealth of Massachusetts Title 5 Official Inspection Form r } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 yoy`?e o/7L I Property Address / )/ W AEd Owner Owners Name /} l ' information isA111 required for every ci V1 14 �s ✓ �� OP fo0� Id Af page. City/Town State Zip Code Date of Insp ctio Cib Inspection results must be submitted on this form. Inspection fors may not be altered in any way. Please see completeness checklist at the end of the for. Important:When A. Inspector In o ation cji{-�f► /$Sly f filling out forms on the computer, use only the tab key to move your Name of Inspector cursor-do not use the return key. Company Name ) QU(JQ =I�y Company Address �V� O j (p`T L �aS q v"I City/Town/ rO� �n D' ��QO State �O ?. Zip Code r /l +J D j Telephone Number License Number B. Certification I certify that: 1 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 maintenanc f on-site sewage disposal systems.After conducting this inspection I have determined that the s 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspectors hignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address /I Owner Owner's Name information is required for every page. City/Town State Zip Code Date of 1ns1kCtiCA C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) ;;n es: 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: 2) System Conditionally Passes: ❑ One or more system components as described in-the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address u if rr'G✓I Owner Owner's Name l information is G1#1� S G� � required for every page. Cityrrown State Zip Code Date of 14ect4fn C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.71262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 /rj�oy'1gQai7� Or Property Address Sf4 61 Owner Owner's Name information is 61#44 s Od 6 0/ required for every page. City/Town State Zip Code Date of Ins ctio C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ;00� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 A Property Address St4 Ava" Owner Owner's Name p information is �� D011)6 0� required for every page. Cityrrown State Zip Code Date of Ins edi n C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z 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. ❑ Re"*— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ � Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must.be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7262018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ISubsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 lloweAe4 Aa Property Address SU Uln H Owner Owners Name information is a�N �/Q Od 60/ /a. 17 required for every page. CitylTown State Zip Code Date of InspettiorV C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes ❑ umping information was provided by the owner, occupant, or Board of Health Elere any of the system components pumped out in the previous two weeks? ❑ s the system received normal flows in the previous two week period? ElHave large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ti Property Address I/� Q Owner Owners Name information is q y T Q� required for every page. City/Town State Zip Code Date of Insp dio D. System Information 1. Residential Flow Conditions: '3 Number of bedrooms(design): Number of bedrooms(actual): ?Q DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): J Description: / 5 OQ 6�`/O N 'G A N / 0s4-r,1 4,� , /?o oC Number of current residents: Does residence have a garbage grinder? ❑ Yes E9-No Does residence have a water treatment unit? ❑ Yes If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? es ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes eNo Last date of occupancy: Date t5insp.doc•rev.7262018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 18 <f'\ Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address P Owner Owner's Name information is AU Qo2 60/ %_Afll required for every page. CitylTown State Zip Code Date of Insfectik D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped. gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fo -Not for Voluntary Assessments 63 Property Address Owner Owner's NameO/ information is RC7 hh ��/�/�y� Lily) required for every page. City/Town State Zip Code Date of Inspe ion D. System Information (cont.) 4. Type of Sy 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/Altemative 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 compoonentWdtenstalled (if known)and source of information:�OI� ��r�� 1 I/_ 4DO ' eO Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron 40 PVC ❑other(explain): A) r Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): t5insp.doc•rev.7262018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments co Property Address llirC Owner Owners Name information is 6O� required for every 7 page. City/Town State Zip Code Date of Ins edi# D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet / Material 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: Sludge depth: ' �^/ 3� Distance from top of sludge to bottom of outlet tee or baffle I Scum thickness Distance from top of scum to top of outlet tee or baffle i Distance from bottom of scum to bottom of outlet tee or baffle R� How were dimensions determined? /e Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): VM /7-ee C4, Giv►� QiN�i � /vI rs /-'p✓1/ /000V Lea-�-1' t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System F rm -Not for Voluntary Assessments r,3 �e ✓� D.- Property Address a /11/G Owner Owner's Name �� f oa�o� % information is required for every page. City/Town State Zip Code Date of Inspe ion D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7262018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address S N Owner Owner's Name O ` O/ Acke information is required for every page. City/Town State Zip Code Date of Insp ion D. Syste nformation (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): IV v o/1 j t5insp.doc-rev.726/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address (03 1%'%?" SC4 ��iva h Owner Owner's Name /� information is required for every /�-�at��� Vol 60/ Id- 1 /V page. City/Town State Zip Code Date of Inspe Ion 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.): i * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: / Type: 111!G � S /yr/b 4ovte— ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments or Property Address I ��Q Owner Owner's Name iequiredifor a Q�h� ad 60� required for every page. Cityrrown State Zip Code Date of Insp ation 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.): Qi* c4fan u/ 0 rf oMc/ih , 64e464 arm✓ 1 Of 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7262018 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fo -Not for Voluntary Assessments 4� Property Address Owner Owner's Name information is a r Qa(C7 required for every page. CitylTown State Zip Code Date of Inspectiofi D. System Tiriformation (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7262018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts a Title 5 Official Inspection Form 1.r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address /Zo ele 04. ja 5,,, Ira h Owner Owners Name V,off S O/ 41( information is required for every Y Pgr page. Cityfrown State Zip Code Date of Inspf3ctioo 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. k one of the boxes below: ❑ h d-sketch in the area below drawing attached separately G S� t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION -G �-(A[3► SEWAGE It O- T VILLAGE W,40 pA 1 l S ASSESSOR'S MAP&LOT�� INSTALLER'S NAME&PHONE NO. vL� -?.. • ���v(&-?.dam SEPTIC TANK CAPACITY LEACHING FACILITY: (type)QUICA Zf S (size) NO.OF BEDROOMS BUILDER OR OWNER C PERMrrDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to theBottom 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 j Furnished by -1 fT 9.3 V-, - Z o _ boo CN q Ue la-1 ('dd C, http://issgl2/intranet/propdata/prebuilt.aspx?mappar=268139&seq=3 11/19/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments vvye ai Property Address Owner Owners Name information is required for every page. City/Town State Zip Code Date of Inspec on D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar �t ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ served site(abutting property/observation hole within 150 feet of SAS) Checked with local Bo of Health-explain:�a h S /� o ✓� "� �C �S o 1-1 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must descri ho ou established the high growatecelevation: L✓ �o-d-e '�L' -) poll fk1 s-,. /,a h,0 . �(/t c c,4 to✓1 16t, LLN ✓i Di Iv Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address V (.4 A Owner Owner's Name information is 60 required for every �!i4h,S i v page. Cityffown State Zip Code Date of Inspection E. Report Completeness Checklist Complete pplicable sections of this form inclusive of: A. I Spector 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 ailure Criteria) and 6(Checklist) completed D. System I 4nformation:: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached ! For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7262018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 a Office: 508-862-4644 Fax 508-790-6304 Installer & Designer Certification Form SA 4L20 Date: l ZZ .1 ( ( a� 2�� ►� l3 Designer: . Installer: Address: —�' ��� Address: qAC vJ t-�6;z,�:4 S-- On (S V was issued a permit to install a (date) (?V; k r) septic system at �� rl(b based on a design drawn by (address) � Avtr) I/. (�� 7(L 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 distribution box and/or septic tank. 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 t of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built b designer to follow. i ki OF 4j4 t god DAVID �%t ,41ller' ISi n ature) D. FL.AHER7Rf,JR. ? j No, 1211 ff # AV (Designer's Signoe (Affix D OWMIamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE ' OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT-CARD ARE RECENED BY THE BARNSTA.BLE P LIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Desiper Certification Form TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE W!J WPA t S ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. j,��tn- : �`�� 2VG m2-y SEPTIC TANK CAPACITY 15D® C3 . LEACHING FACIL=: (type) .2L--7 aug'k �—{ I`S (size) NO.OF BEDROOMS BUILDER OR OWNER C h'-r-(6 "f`gki IBC e lk PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by tam; ffi V 00 � N sL 0 p No.20 I I ^ gob i Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered incompute : �PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zippiication for 7( Upg,,d, a *Vstem Construction Permit Application for a Permit to Construct( ) Repaii ( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. b3 b�tev0,91r YP2 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 5 �° .� r S ✓�mot, Type of Buil ng: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building h)z e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 233 gpd Design flow provided 33 6 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank /500 Type of S.A.S. 9,q L/�5 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 Certificate of Compliance has been issued by this Board of Health. Signed Date 11/9-1111 Application Approved by Date It Application Disapproved b Date for the following reasons Permit No. 2©1 I— q o'D Date Issued Z ZD 1 1 No.Zo I q06 Fee�a��/ THE COMMONWEALTH OF MASSACHUSETTS Entered in conipuer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 9pplication for I8 asal *pstem Construction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components w =Location Address-or LotiNo. bmepg;= `'P& —!0" Owner's Name,-Address,and Tel.No. t Assessor's Map/Parcel a(p'? — 191 ti' 'OS ���. T. Vz Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �1 h t✓ �►LIG ., , t /'f ,S S ulp-?t Type of Buil g: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building e- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 33 gpd Design flow provided 33 6 gpd Plan Date Number of sheets Revision Date s Title Size of Septic Tank �Jr C Type of S.A.S. R4 quid q5 Description of Soil I 1 Nature of Repairs or Alterations(Answer when applicable) /Aeu/ a- //l!�e s / j ;L- I Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in i accordance with the provisions of Title 5 of the Enviro mal Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health Si f Date Application Approved by t Date l� ,7 Zo Application Disapproved b Date for the following reasons 1 Permit No. •1 I L/0 Date Issued _ . ------------------- _ -=--- -- --- ---------------- -------------------- THE COMMONWEALTH OF MASSACHUSETTS, BARNSTABLE,MASSACHUSETTS Certifitate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V)Upgraded( ) !p 5 Abandoned( )by ROji'144,1- at (p 3 N DMe 011� n(L has been constructed in accordance } 1 It � ZI,Z� with the provisio�g of itle 5 and the )_for Disposal System Construction Permit No� 1-`i" dated tI Installer (� � ,St� �— Designer S JCU�.�2 G. #bedrooms Approv design w �3 gpd The issuance of this permit shall Jab e c n t ed as a guarantee that the syst m will fit cti l as d si n1 2 Date D Inspectors Zoo q00 Fee���' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pste Construction Permit Permission is hereby granted forr Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at 03 �oM e 5,o r(, Piz- and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. i Provided:Co structi n must be completed within three years of the date of this pern Date l z l Z O 1 I Approved by - I j Town of Barnstable Regulatory Services Thomas F. Geiler, Director BARNk4BLF, � MA88. Public Health Division °tine Thomas McKean,Director 200 Main Street,Hyannis,Mk 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form D vliv� 00(1 — 4-j0 Date: Designer: � Installer: (Sv�'�V_ g � II.. 11 Address. Address: qAQ 4-6;z&4 On (�2� —1 \ S V was issued a permit to install a (date) (' taller) septic system at Y VD41 vj�'_ n 16 based on a design drawn by (address) 7(L 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 distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built b designer to follow. 9� DAVID 4Installer'/Slinature) D n FLAHER'rX JR, No. 1211 71 ��N� M (Designer's Signa e (Affix Desi � YS amp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILYCARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Desiper Certification Form Town of]Barnstable P# ' Department of Regulatory Services aR&MUMBM i Public Health Division Date - -'el j 0 200 Main Street,Hyannis MA 02601 Date Scheduled Time Fee Pd. l Foil S itability Assessment fog- Se age Disposal Performed B �� Yj� Y' Witnessed By: . LOCATION&GENERAL INFORMATION Location Address / !7 /1jOwner's Na/me ���Y y�`J Address "` JL Qr Assessor's Map/Parcel: /Op ��j �Q/l �3Gf Engineer's�Na�me A OZ5-4 NEW CONSTRUCTION REPAIR Telephone# 52 l" 36 6 Lo � -c Land Use: _ Slopes M r! Surfaccee^SS ones✓✓v� / Distances from: Open Water Body Possible Wet Area ft Drinking Water Well t Draihage Way ft Property Line m /1� 1 7 ft Other SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands•I'n proximity to holes) � I i L -!L A i Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater 2 DETERIVIINATION FOR SEASONAL HIGH WATER TABL Method Used: Depth Observed standing in obs.hole: In, Depth to soil mottles: In. Dcpth to weeping from side of obs.hole: _ ---In, Groundwater Adjustment fr. Index Well# ea ingDate:Ye=::�—_ wex Well level factor. ,�.. dj.Clraundwa r Level> /A � PERCOLATION TEST bate ��"/ Thne l z Observation Hole# / d Time at 9" Depth of Peru 2!` Time at 6" /e Start Pre-soak Time @ !i Time(9"-0) End Pre-soak wl � r Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back------� ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC f l DEEP.OBSERVATION HOLE LOG Hole# _1� gv, d Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. o i ten_y,% raven ¢ 75. DEEP OBSERVATION HOLE LOG Hole# 1C & .0 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. _ onsis en %Gravel) /b'e 2y DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency, Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes...r Within 100 year flood boundary No._T__. Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervioug material exist in all areas observed throughout the area proposed for the soil absorption system? / If not,what is the depth of naturally occurring pe ious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of VIM mental Protection and that the above analysis was performed by me consistent with . the required trai " p tise a If el perience described in 10 CMR 15.017. Signatur Date QASEPTlWERCFORM.DOC i • � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M ,•''v 63 Home port Drive Property Address Mike Tirrell Owner Owner's Name information is required for Hyannis Ma. 02601 8/14/2007 every 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. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key (� Z to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name P.O.Box 763 Company Address Centerville Ma. 02632 °f City/Town State Zip Code (508)428-4028 S14454 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 maintenanq f 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: -s ® Passes ❑ Conditionally Passes ❑ Fails _ ❑ Needs Further Evaluation by the Local Approving Authority - 3 c� 01 1711 8/14/2007 Inspector's Si6nafi5re 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. t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 `.4Tf Commonwealth of Massachusetts W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 63 Homeport Drive Property Address Mike Tirrell Owner Owner's Name information is Hyannis Ma. 02601 8/14/2007 required for y every P9 a e. 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: The septic system is in proper working order at the present time. 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, 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 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 ❑ obstruction is removed t5insp•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 63 Homeport Drive M Property Address Mike Tirrell Owner Owner's Name information is required for Hyannis Ma. 02601 8/14/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: f ❑ 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 ❑ obstruction is removed ND Explain: 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 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. t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 63 Homeport Drive Property Address Mike Tirrell Owner Owner's Name information is required for Hyannis Ma. 02601 8/14/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 ❑ ® 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 El ® 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Homeport Drive Property Address Mike Tirrell Owner Owner's Name information is Hyannis Ma. 02601 8/14/2007 required for y every page. City/Town State Zip Code Date of Inspection B. Certification (coat.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ® 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 ❑ K well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in.a nitrogen.sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts } Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Homeport Drive Property Address Mike Tirrell Owner Owner's Name information is Hyannis Ma. 02601 8/14/2007 required for Y every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks?. ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part.of this inspection? ® Were as built plans of the system obtained and examined? (If they were not El available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. El ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 f - - Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 63 Homeport Drive Property Address Mike Tirrell Owner Owner's Name information is required for Hyannis Ma., 02601 8!14/2007 every page. City/Town State Zip Code Date of Inspection 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 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? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, iUavailable last 2 ears usage d 2007: g ( Y g (gpd)): 2007:18,750, Sump pump? ❑ Yes ® No Last date of occupancy: 8/14/2007 r Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑, No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 63 Homeport Drive Property Address Mike Tirrell Owner Owner's Name information is Hyannis Ma. 02601 8/14/2007 required for y every page. City/Town State Zip Code Date of Inspection ®.-System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises,LLC Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 750 gallons gallons How was quantity pumped determined? measured Reason for pumping: pumped as part of inspection.. 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) El maintenance 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: 40 years Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 63 Homeport Drive Property Address Mike Tirrell Owner Owner's Name information is required for Hyannis Ma. 02601 8/14/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 14" Depth,below grade: feet Material of construction: .® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20'+ feet f Comments (on condition of joints, venting, evidence of leakage, etc.):. Joints appear tight.No evidence of Ieakage.System vented through the house vents. y Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ---------------------------------------------------------------------------- ---------------------------------------------- Dimensions: l 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 were dimensions determined? t5insp-08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Homeport Drive Property Address Mike Tirrell Owner Owner's Name information is required for Hyannis Ma. 02601 8/14/2007. . 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.): J Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle ` Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 63 Homeport Drive Property Address Mike Tirrell Owner Owner's Name information is required for Hyannis - Ma. 02601 8!14/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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.): r *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: l ❑ Yes ❑ No t5insp•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i i 63 Homeport Drive Property Address Mike Tirrell i Owner Owner's Name information is Hyannis Ma. 02601 8/14/2007 required for y every page. City/Town State. Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I - i i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ 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.): t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts ti W Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Homeport Drive Property Address Mike Tirrell Owner Owner's Name information is Hyannis Ma. 02601 8/14/2007 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1-main and 1-overflow Depth—top of liquid to inlet invert 1' 4" Depth of solids layer 3„ Depth of scum layer Dimensions of cesspool 2-61x8' concrete block 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.): Main cesspool was full to outlet invert at time of inspection.Overflow cesspool was dry with stain lines 50"to invert.No signs of hydraulic failure. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition,of vegetation, etc.): i t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts w Title 5 Official inspection Form Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments 63 Homeport Drive Property Address Mike Tirrell Owner Owner's Name information is required for Hyannis Ma. 02601 8/14/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 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. I i i - j i t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 63 Homeport Drive Property Address Mike Tirrell Owner Owner's Name information is required for Hyannis Ma. 02601 8/14/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: Bottom of cesspool 18'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) l ❑ Checked with local Board of Health -explain: r ❑ Checked with local excavators, installers- (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water.elevation: Used:Gaherty& Miller model 12/16/94 ground water elevations. Used:USGS Observation well data June 1992. USED:Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 63 homeport-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TBM: _ VARIANCE REQUESTED: HYANNIS TOP OF NAIL=30.14' • — — — — _ — _ _ _ _ — QM cn 0e TO INSTALL S.A.S. AT 18.3 & L!-" T �RI VE 19 OF3THE 20'' FROM REQUIREM NT FOUNDATION N LIEU O 29.5 Co . � ,Q TO � IX . G ErW �q0 I HOM PORT 130 581 .2 43 E \ �� DR. N 76.78 1 CB SMITH N 1 G o sT rn I ^00 \ -- I { S \ TH2 _ _ �O \ I 0 35.2 r - - _ -- — _ — 29.5 LOCUS MAP 30.0 G 1 \ — -x— _ % LOCUS INFORMATION PLAN REF: 197123 1 TH1 I ASPHALT 0HW TITLE REF: 23821/27 00 PARCEL ID: MAP 268 PAR. 139 1 29.8 L _ _ DRIVEWAY ZONE: "RB" "WP" DISTRICT PARCEL ID: 3 LOT 20 3� X _ _ _ _ — - _ — f FLOOD ZONE: C _ I COMMUNITY PANEL: 250001-0008-D DATED:07/02/92 10, 8.5 I / / I ► - - - - SEPTIC SYSTEM DECK I I I ENCL. / / / / / CB REPAIR PLAN I I SCREENED I I I LOCATED AT: / / / / lv Q 18,3' PORCH I #63 HOMEPORT DRIVE Iz / / / / / / / / / / � / / I � 1 I HYANNIS, MA. ILL- N z PREPARED FOR I Q w / / � / / i / / / / � / / I � I I I o z o I CHARLES D., JR. & TERRI I o o 30. / / I REID N (o � CN -i X / / / - - / / / I I I SCALE: 1"=10' n I �`` M co / / / #63 / / / LO I i;�W' \ , 10' p� / / / / / / I I W I NOVEMBER 17, 2011 o W I z I oW `r 0 ~oo / / 3-BEDROOM / / / I I ��(HOFMgS e3����FSS9 �a PR0P. v�ZR / / / / / / I O 1500 aW / / / RANCH / / 1 1 0�� D I 9O o�� EDXAIA cyG TANK ~`�0 / / , TCF=30.81' ��F H 0 A. STONE N� O N o. 1211 No. 289 wcnduuj 0-1 QQU / / , / /_ LOT 19 w. I ���sTER� s T O E 1 � U(aQ N I� SgN17AR N N 1 SHED 1 / 19.3 PARCEL ID: DB / / / 268/139 M Iw 1 (TO BE i I RELOCATED) ANEA=7,710f S.F. Z I 13.0' X, I J E. A. S. I � I 30.7 29.6 o I SURVEY, INC. 141 ROUTE 6A LOT 21 SALT POND BUILDING PARCEL ID: S85'26'40"E _ I P.O. BOX 1729 268/141 io 0 5 10 — -— _ _ FENCE _ 1 SANDWICH, MA. 02563 L 100.00 LOT 18 ( PARCEL ID: {�IN FEET ) PARCEL 8 iI BUS:(508)888-3619 CELL:(508)527-3600 1 inch = 10 pt. j SHEET 1 OF 2 J 1386 TOP OF BLOCK FOUNDATION EL=30.81 4" SCHEDULE 40 P.V.C. PROFILE OF (10' MIN.) MIN. PITCH 1/8" PER FOOT SEWAGE DISPOSAL SYSTEM OBSERVATION W/SCREWCAP PORT EL=30.0 (NOT TO SCALE) TO GRADE EL= 30.0 EL= 30.0 I .........::.,,.... ::.�•,,,,,::::::::;:� :;;::;:>�::>::,a:::;;;:::;::a,,.,ZS= .04 EL= 30.0 EL 30.0 4-BAND STAINLESS 6" MAX.' „ „ ... ,,,,,,, STEEL 9" MIN. „'„ :: :::;; :::......,;:Flc+±±a„. , ...... 6" MAX. COVER 6 MAX., CONC. I "CLEAN 'SAND „FILL`"," CONNECTOR. RISER & PER 310 CMR 15.255 EL= 29.45 LEVEL INVERT BETWEEN AND TO A MIN. OF 6" 28.. COVER FOR 2' EL= 27.33 . OVER UNITS CA 10' 0 S=.02 , a SCH40 PVC FLOW LINE .0 S=.Ot EL= 27.67 110" 14" INVERT EL=28.61 EL=28.40 MIN. EL=27.72 INVERT6 SUMP EL=27.45 r o 8"lvvvvvvm 12"INVERT INVERT GAS m EL= 26.67 (EXIST) BAFFLE8' BASE OF MECHANICALLY COMPACTED SAND 32.0PROP. DB3 DISTRIBUTION 24-QUICK 4 STANDARD INFILTRATORS 71 8' BASE OF MECHANICALLY " " " COMPACTED SAND BOX (34 W X 48 L X 12 H) EACH l PROPOSED SOIL ABSORBTION SYSTEM (S.A.S.) 1 ,500 GALLON TANK (BED FORMATION) 8.5' X 32' g VARIANCE REQUESTED: 34 -MIN. CLEAN SAND FILL EL= 27.67 7 TO INSTALL S.A.S. AT 18.3 & EL=A:� 19.3' FROM FOUNDATION IN LIEU �'-_ OF THE 20' REQUIREMENT EL= 2s.s7 g.50' I GENERAL NOTES END VIEW BOTTOM OF TH #2 ELEV.= 18.5 11 (NO GROUND WATER) 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. I CERTIFY THAT I AM CURRENTLY APPROVED BY THE DEPARTMENT OF TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS ENVIRONMENTAL PROTECTION PURSUANT TO 310 CMR 15.017 TO CONDUCT FOR SUBSURFACE DISPOSAL OF SEWERAGE. SOIL EVALUATIONS AND THAT THE ABOVE ANALYSIS HAS BEEN PERFORMED 2. ALL ACCESS PORTS OVER TANK TEES SHALL BE BY ME CONSISTENT WITH THE REQUIRED TRAINING,',,EXPERTISE, AND EXPERIENCE DESIGN DATA: FIN ACCESS PORTS BROUGHT TO WITHIN 6" OF FINISH GRADE. I ACCESSIBLE WITHIN 6 OF FINISH GRADE, ANY REMAINING DESCRIBED IN 310 CMR 15.017. I FURTHER CERTIFY THAT THE RESULTS OF MY I 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE SOIL EVALUATION, AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM, NUMBER OF BEDROOMS......... 3 CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE ARE AC URA E A D I A CORDANCE WITH 310 CMR 15.100 THROUGH 15.107. GARBAGE DISPOSAL.................- NO UNDER OR WITHIN 10' OF DRIVES OR PARKING AREAS THEN THEY TOTAL ESTIMATED FLOW MUST WITHSTAND H-20 LOADING. 330 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION (110 GAL./BR./DAY X 3 BR.) _ _ OF ALL UTILITIES PRIOR TO ANY EXCAVATION. EDWARD A. STONE, CE TIFIED SOIL EVALUATOR 330GPD X 200% = 660 .GAL 5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE USE NEW 1500 GAL. TANK OR WITHIN 6" OF GRADE SHALL BE MORTARED IN PLACE. INSTALL: s. FINISH GRADE SHALL HAVE A MINIMUM OF 2% GRADE OVER THE S.A.S. AND DISTRIBUTION BOX. TEST PIT RESULTS: P 3459 . 24 QUICK4 STANDARD INFILTRATORS (34"W X 48"L X 12"H)7. SEPTIC TANK SANITARY TEES SHALL BE CONSTRUCTED OF AND BACKFILL WITH CLEAN SAND FILL PER 310 CMR 15.255SOIL TEST DATE: NOV. 15, 2011 (8.5' X 32') SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6" ABOVE THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND B.O.H. AGENT: DON DESMARA'1S, R.S. SOIL CLASSIFICATION................__ LOCATED DIRECTLY UNDER THE CLEANOUT MANHOLES. SOIL EVALUATOR: EDWARD A. STONE 8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN DESIGN PERCOLATION RATE..... <2-M1LL,,/b. 2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT BACKHOE: RODNEY FISHER EFFLUENT LOADING RATE......... ELEVATION OF THE OUTLET PIPE. � REQUIRED LEACHING CAPACITY.....330 GAL DAY 9. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES. 10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS LEACHING CAPACITY PROVIDED.....336 GAj=/DAY BAFFLE, 4 INCHES IN DIAMETER AND CONTRUCTED OF 4" PVC.11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND TH#1 EL.=30.0 PERC RATE<2MIN./IN. ©52"BOT. (3) ROWS OF (8)INFILTRATORS X 4.73 S.F./L.F. FIRST TWO FEET OUT OF THE DISTRIBUTION BOX SHALL ELEV. DEPTH IN.) HORIZON TEXTURE COLOR MOTTLING OTHER 96 L.F. X 4.73 S.F./L.F.= 454 S.F. BE LEVEL. S.F.= 336 GPD GPD X S.F. . .12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION 29.5 0"-6" A LOAMY SAND 1OYR5/3 --- ----- 454 / TO EAS SURVEY, INC. FOR B.O.H. AND DESIGN 28.3 6"-20" B LOAMY SAND 7.5YR5/6 --- ----- ENGINEERS REVIEW AND APPROVAL. 336 GPD PROVIDED - © PD REQUIRED = 6 GPD RESERVE 19.0 20"-132" C COARSE SAND 2.5Y6/6 --- -PERC. NO GROUNDWATER/NO MOTTLES OF CONSTRUCTION NOTES: �����N ss9c o2��EDWARD s`�� SEPTIC SYSTEM DETAIL PAGE 1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND TH#2 EL.=30..0 o DAVI ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING D. ELEV. DEPTH (IN.) HORIZON TEXTURE COLOR MOTTLING OTHER o 3 #63 HOMEPORT DRIVE WORK ON THE SITE. " " v FLA F2 ,J p• o a 2. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE 29.5 0 -6 A LOAMY SAND 10YR5/3 --- ----- 12 HYANNIS, MA. WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT 27.67 6"-28" B LOAMY SAND 7.5YR5/6 --- ----- F �� '� G I Sl NOV. 17, 2011 IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. sTE� si N �� N 18.5 28"-138" C COARSE SAND 2.5Y6/6 ----- ---- SAINITA �P �a 3. ALL SYSTEM COMPONENTS SHALL BE MARKED WI1N MAGNETIC MARKING f` � - - f!' � SHEET 2 OF 2 J# 1386 TAPE OR A COMPARABLE MEANS. NO GROUNDWATER/NO MOTTLES C