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HomeMy WebLinkAbout0080 HYANNIS AVENUE - Health _:U rjyunnis Ave Hyannis A= 287-123 1 t` 0 0 u 1 TOWN OF BARNSTABLE � . LOCATION L� AfLe SEWAGE# VILLAGE A_ ASSESSOR'S MAP&PARCEL 28 7-Q3 INSTALLER'S NAME&PHONE NO. IllC SEPTIC TANK CAPACITY _ 0 LEACHING FACILITY: A S Z - > size /3 L3Sf ce3 (size) NO. BEDROOMS OWNER PERMIT DATE: '-)131100 COMPLIANCE DATE: v 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 J e4' b $A1 �1 9 p b 0 t ' Commonwealth of Massachusetts (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Hyannis Ave. Property Address F" Plunkett -> Owner Owner's Name information is required for every Hyannisport V MA 02601 5/6/19 ' page. Cityrrown State Zip Code Date of Inspection y_• P+ 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. Inspector Information I3 7 Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 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 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 5/6/19 Inspecto gnatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 �/ oa Commonwealth of Massachusetts 9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o 80 Hyannis Ave. Property Address Plunkett Owner Owner's Name information is required for every Hyannisport MA 02601 5/6/19 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/26/201 S Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett Owner Owners Name information is required for every Hyannisport MA 02601 5/6/19 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 ❑ 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: 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 80 Hyannis Ave. Property Address Plunkett Owner Owner's Name information is required for every Hyannisport MA 02601 5/6/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett Owner Owner's Name information is required for every Hyannisport MA 02601 5/6/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public 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 CM 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 Lmnsp.,doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett Owner Owners Name information is required for every Hyannisport MA 02601 5/6/19 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑` Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? • ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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 �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett . Owner Owner s Name information is required for every Hyannisport MA 02601 5/6/19 page. CityrFown 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: 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 ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Seasonal . Date t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett Owner Owner's Name information is required for every Hyannisport MA 02601 5/6/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No 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: Pumped last fall per owner 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett Owner Owner's Name information is required for every Hyannisport MA 02601 5/6/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 2009 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett Owner Owner's Name information is required for every Hyannisport MA 02601 5/6/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-20 tank, Inlet cover raised to 12", outlet cover raised to 6" If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: trace Distance from top of sludge to bottom of outlet tee or baffle '12 Scum thickness trace >2 Distance from top of scum to top of outlet tee or baffle �2 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts ,19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett Owner Owner's Name information is required for every Hyannisport MA 02601 5/6/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett Owner Owner's Name information is required for every Hyannisport MA 02601 5/6/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0,. 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.): H-20 d-box is 20" below grade, cover raised to 6", very good condition t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 \ Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett Owner information is Owner's Name required for every Hyannisport MA 02601 5/6/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: Teaching trenches, number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 113 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett Owner Owner's Name information is required for every Hyannisport MA 02601 5/6/19 page. City/Town 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.): Chambers were video inspected and are dry at this time, no indication of pats hydraulic failure, top of chambers is 3'6" below grade 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts (e Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett Owner Owners Name information is required for every Hyannisport MA 02601 5/6/19 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts - - Title 5 Official Inspection Form f' b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i� 80 Hyannis Ave. Property Address Plunkett Owner Owners Name information is required for every Hyannisport MA 02601 5/6/19 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately a— 1 � ` t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett Owner Owner's Name information is required for every Hyannisport MA 02601 5/6/19 page. Cityrrown State Zip Code Date of Inspection- D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >120" 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: 2009 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4' seperation per 2009 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping, site is 18'msl and nearby surface water is 2'msl You must describe how you established the high ground water elevation: see above 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 Iig Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Hyannis Ave. Property Address Plunkett Owner Owner's Name information is required for every Hyannisport MA 02601 5/6/19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 �M6 •6Q F J r 4J - No rFee THE COMMONWEALTH-OF MASSACHU.SETTS Entered in computer: Yes PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for.33ioozat &pgtem Construction Permit Application for a Permit to Construct()()Repair( )Upgrade( )Abandon( ) X Complete System El Individual Components Location Address or Lot No. 80 i-l�ah hcs f� Owner's Name;Address and Tel.No. (-{yCswr�iS �G`i"F CPYr�ce�� 17tve�dfc� l.eY0-C McShnz, I.4.0 Assessor's Map/Parcel p� c 1"A9� Z?7 tBa,ccl � 3 , �s4 , Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 5dr-77A:-752C2;exd'/3 r-19,161 .r y8•S� 7 r� 14 1 Type of Building: Dwelling No.of Bedrooms "7Arrr_ Lot Size clo sq.ft. Garbage Grinder(4/47) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow �/��� :1_=U gallons per day. Calculated daily flow -33 0 gallons. Plan Date Number of sheets an F Revision Date 7—V- Z00 i Title lea 90 Size of Septic Tank Ir 6 E e,U60 s. Type of S.A.S. A,uac tn% C1-aamh-e,-� AZ 6sc3� X Z' Description of Soil .6 nni l 6! Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee ' ' ued his Boar Health. y Signe Date __,b�406 Application Approved by Date Application Disapproved for the following reas n Permit No. Date Issued � ~ F�' � � • '� �J�mow/ V � 5 � � - _ `No. Fee Lo ' R THE CO MONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION TOWN OF BARNSTABLES MASSACHUSETTS ! 1 / 4, { J Applicatioti for Wgpool *pgtem Con!5truction Permit Application for a Permit to Construct( )�Repaii( �)Upgrade( )Abandon-(: ) 134mplete System El Individual Components Location Addressor Lot No. 80 ")4nh t.s A,,,x Owner's Name,Address and Tel.No. Hrjatints Porr-+ Grti3or7 9(-n1cci � Lcrn4-c t`cst-jha Assessor'sMap/Pazcel K6. 13oiL 69 QC 00'sS OLVI3 i11R1� 2f17 t�urGCl IZ3 � i Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. " 5-cf-771-7502;exf'13 Hrd dYu� S�c�ru�t .4 Witswt, / 3^ 1-6V8 F9 7 d „>1is Type of Building: . Dwelling No.of Bedrooms 7-Arrc, Lot Size S 01/0 sq.ft. Garbage Grinder( IVJp Other Type of Building "' No.of Persons Showers( ) Cafeteria( ) Other Fixtures �s �'.Design Flow //0 kdrom" gallons per day. Calculated daily flow 33 Dgallons. ' - Plan Date /0-/T-Z001 Number of sheets OA r- Revision Date 7-Z/- Z-00� '• Title Sc'ehc- Srisfa.a 12e.ai Sn 90 14se cnms A,,r= _Size of Septic Tank I TO yc//c#► Type of S.A.S. ticschin, Ch4ar is IZ'x3S x"Zr,Xi `Description of"Soil -&J= -6 -66 l O o 9 S 121-2h R-`?595 :4 xw r- Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: >t r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage dispos 1 system r :in accordance with the provisions of Title'5 of the Environmental Code and not to place the system in operation until a Certifi- r..l 'cate of Compliance has been 0ssned'b VAs oard of lth.Signed _' t Date rl / ~© Application Approved by Iii� Date.` � t Application Disapproved for tthe4ollowing reasoys Permit No. Oyu y .� Date Issued THE COMMONWEALTH OF MASSACHUSETTS JJ��(' �y Q o rav�'1 S ..BARNSTABLE, MASSACHUSETTS ` 3 �ertifxt ate of,,,CompIiance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( Repaired Upgraded( ) Abandoned( )by at Vj L has bee constructed in accordance .. with the provisions of Title 5 and the for Disposal System Construction Permit No. ated Installer Designer The issuance o th's permit shall not be construed as a guarantee that the syst w 1 mction as d signe�. Date 3 = Inspector - -- ----- --------------�----------�-- No. Fee THE COMMONWEALTH OF MASSACHUSETTSg4f k t1 PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mi!6poga1 *pgtem Cougtruction Permit Permission is hereby granted to C st t( tepair( )Upgrade( )Abandon( ) System located at �a , and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Dater Approved by ` Town of Barnstable oFIME A Regulatory Services Thomas F. Geiler,Director ASTABLE, i Public Health Division 9�Ar 1639. 1% � Thomas McKean Director ED Mp`l 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 'Fax: 508-790-6304 Date: Sewage Permit# 2005 29Z, Assessor's Map/Parcel 287 I23 Installer& Designer Certification Form Designer: 54'901 CN Installer: Dow G2crktris Address: Qa x 1zr Qs3c Address: Htcjee!,� ( uvJvv,=hun 7f4 32F IRCeo rK Hp nls On 7 3.000 9 CqivUcd-zcn _was issued a permit to install a (date) (installer) septic system at 80 4--{�Aonvii5 Aun , P�&Knis f6r-+ based on a design drawn by (address) Slzr h-h A W 11scai j PE dated 7 (designer) �C 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. Stripout (if required) was inspected and the soils were found satisfactory. - ._E:�i-hW 34pyJz4. ks H-Zmo SOp 5c flvr� Ic�c b.;�c� e_ka.wbcr* in I eo --�-- I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if requir ' spected and the soils were found satisfactory. IH OF� MqS��� O STEPHEN y� ALLYN m Installer's Signature) WUSON . No.30216 Co �� TER�o� a�Q 'A Ail e igner's Signatu e) (Affix DengjqWWamp 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. 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I I f J V r �Rtt � I Jl� _ II r ! 190 1 1 N_Zz r I 12] R nr SG / a - 1 7n V I " w - 7V _j m � a S Y VI J V q Z C. --- R CD — 1 I r � i- f 3 — do VIE Cm_ UEN 50 �. _ _. — a __Qi r �•o o •tea• • . . - =� r_..--_-�._»—.._.... ..._... —._ ••� •- +�-- A , � •--lit, . tEO"x36�.r.. , �Ncy vt<R 4attvva. uuvstt __..��.. OW. s9 t0 �D 2e , ►I—t.�I� — . •n •� . it '' •' `` (' .. �,. . . .. :. . :-�•---.. •-.w b 1 •. � .. IT ' uT - N o � s 1• f4 tG atf - g:a - _-: _ .:-t:b.. Q.3�` ��.6•' T:�.` •3. '.�$" S'.O G.G, 2.6" 20 'i•b T,Q '1..0 't.p 2.O Q•a.j: : _ .r �.G--- - — �- ,� �. • .... . . . .... . _ .. . ..sEco.��r� r�R PLAN .24 sue.•. . _ J/IOR�M:LA1fW lltaIDlfT �, AT��H1 M # scA�E: lI •. . AP�RovEDer: :1-� DRAW SY DATE 4Jr1� � REVISED - OIl1o�608��d�•CicxUs.�-4I0.07S0 - _...._. DRAWING NUMBER 50 hI u�IcC' 0007-6 7 y DESIGN SCHEDULE ELEVATION Leaching Area Requirements TOP OF FOUNDATION 23.0 3 BEDROOMS AT 110 GPD/BEDROOM - 330 GPD ®� SEWER INVERT AT FOUNDATION 20.0 v' SEWER INVERT INTO SEPTIC TANK 19.8 PERC RATE _ a MIN. / INCH (CLASS 1 ) c SEWER INVERT OUT OF SEPTIC TANK 19.5 LTAR = 0.74 GPD/S.F POND LaT 2 �' `�= SEWER INVERT INTO DISTRIBUTION BOX 19.3 PLAN BOOK 198 PAGE 23 �'`csx SEWER INVERT OUT OF DISTRIBUTION BOX 19.1 MIN. LEACHING AREA OF SAS. I SEWER INVERT INTO LEACHING SYSTEM -1-1&9 BOTTOM OF LEACHING TRENCH 1&9 330 GPD/ 0.74 GPD/&F.= 40 S.F. MIN. WATER TABLE - NONE OBSERVED AT ELEV. 5.6 d PROPOSED SYS71V : 12' X 35' X 2' (ht) LEACHING CHAMBERS s SIDEWALL (12' + 35') x 2' x 2 = 188 S.F. �$ I �? 80TTOM (12' X ,35� 4 `N ° 8 ' 133.735�t�DIMENSION ° \ 608 S.F. FOUND 1 133.50 - IP TO ANGLE POINT I� IP FOU WANMS x 1 1 .69' - ROAD SIDELINE TO ANGLE POINT \ 11 ® IWtBOR = w PROP. WAT W x LOCUS MAP - f " NTS � I ZONING DISTRICT RF-1 I I / OVERLAY DISTRICT: PROPOSED DR RICT: AP �I SPY I I BUILDING SETBACK REQUIREMENTS FRONT- 30 SIDE= 15 REAR= 15 LOCUS PROPERTY IS COMPRISED OF: ASSESSOR'S MAP: 287 LOT: 123 z LOT 1 0 PLAN BOOK 198 PAGE 23 F1 •..:�•1'- DEED BOOK 13 955 PAGE 54 .•�, ; 1.5 WASHED STONCj, ' � MIN. 25.00 ��ti r. 11-4 10' ` "S / \ ,` \ I \ � �=� �., � • .: it7.�•� COMMUNITY PANEL NUMBER 250001 0006 D I 1 O \ \ \ -, - :. ' 7%i•,s• :i.• f I.R.M. MAP ZONE C 35' REFER TO ZB A DECISION: 40N LOT i22-1 APPEAL #2004-0$6 IL \ PLAN BOOK 5" PAGE91 1 8 \ TEST PIT `� \ s NSF o'NEIL PLAN OF LEACH CHAMBERS a c 11 \\ PROPOSED, HOUSE S 1 \ \ o\ c w PROPOSED BRICK'WALK \ T.O.F. = EL 23.0 1 \ ; NO', SCALE H `� 10' MIN. 20' i \ \ \ GENERAL NOTES g1 N. \\ TEST PIT Z ' 1 �` 25.00'/ I \ FINfSHED GRADE ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE I I 1 �/ I \ _ T ( P WITH TITLE OF THE STATE SANITARY CODE DATED MARCH 31, i 1 1 36'MAX. 9 IN. ACTED FILL 1995 & ANY LOCAL RULES APPLCABLE Z \ �E 1 ,co I \ \ 2 AL OR FILTER FABRIC ANY CHANGE TO THIS PLAN MUST BE APPROVED IN WRITING BY •/ �$ \ I a •i . _ • : ° THE DESIGNING ENGINEER. i x 1 2S oo' \ PROPO�S�D 16'x25' TERRACE I \ 30.5" ,� ,, : • :. 3/4 TO 1 1/2 24 y ,; .• DOUBLE WHEN CONSTRUCTION 6 COMPLETED, PRIOR TO BACKFILLING, \ z (EL 22.2) 11 \\ EFFECTNE WASHED STONE ' NOTIFY THE ENGINEER A BOIARD OF HEALTH AGENT FOR x \ v x \ x x DEPTHi0. fNSPECTiON. ALL SANRARY DISPOSAL SYSTEM PIPING TO BE 4' PVC, SCH. LOT AREA �� \ \ NO SCALE 40. r ` \ / f15,040 5F `\ \ . EXCAVATE AND REPLACE ALL UNSUITABLE MATERIAL ` \I / t0.35 ACRES \ \ SURROUNDING SURROUNDING THE LEACHING FIELD FOR A PLASTIC LEACH CHAMBERS\ x \ � \ \ DISTANCE OF 5, PER 310 CMR 15.255. \ \ PRIMARY BENCHMARK : NW R U Se (3 S7y CULTEC 330 0 EQUAL ...�tT PROJECT BENCHMARK : SEE PLAN \\ \ 8 � 'a' GATE LOCATION OF UNDERGROUND UTILITIES ARE APPROXIMATE AND \ CB SHOULD BE VERIFIED IN THE FIELD BY THE APPROPRIATE UTIUIY BENCHMARK I I \ 16 . ' CB TO ROAD F�oUND 46.42_ _ .33OXaO COMPANY PRIOR TO ANY 163 L ELEV 2OL 83#25N7 VD IP FOUND ( 16309 - CB TO IRON PIPE S 64'1T22' E ��� AKE FOUND --_..- \ `16� 7� DEED DIMENSION w �--EEDGEE OF PAVEMENT Z z -�^ w x 1 \ Id" ` bit Gj`/ f �Uv !/�Gl✓il�Wa U n J �� 3 ' `\ 'po 80 Hyannis Avenue o Hyannis Port, Massachusetts IN LOT 5 PLAN BOOK 55 PAGE 27 PREPARED FOR N/F DOHERTY Gregory Plunkett * I Cf i SWEETSER ENG TITLE SOIL LOG; #P-9529 DATE: 9/30/99 septic system Design Q SOIL EVALUATOR: BOARD OF N F*00 GUM = 220t TYPICAL SYSTEM PROFILE Tad Duff= HEALTH AGENT BAR NYE ENGINEERING & SURVEYING MOANHOIoVER T D. TO TA Tn AT LEAST �m T°2 NK 10 : '{ wmm 90 Fmsm GRADE NOT TO SCALE TEST PIT 1 TEST PIT 2 15.6 t 15.6 t Registered Professional Engineers and Land Surveyors cli :•i_ FINIM ` °WR '"W _ 22'0t INS in FIN190 GRADE o>�R a soot . 22ot ADJUST to ram' � - 78 North Street-3rd Floor,Hyannis,Massachusetts 02601 F1�ED GRADE OM LEAN" SMW • �Of ° A LOAMY SAND 0 A LOAMY SAND �- Phone-(508) 771-7502 Fax -(508) 771-7622 6'>rMV. ( •) - seELowGRAD� 12" 10 YR 3/2 15' 10 YR 3/2 4' SCH. 40 PVC 4' SCH. 40 PVC .• FIRST 2 (TO BE LEVEL) �� � " 9� 10 0 10 20 r 36. ( � Cover B LOAMY SAND B LOAMY SAND �P�ZN of Ails 10YR618 M 10YR6/8 ,�� t:..: tu• 14• �;' 40 39 7 EPHl N L �, SCALE IN FEET 210yer 1/8101/2' BAFFLE SUMP C SCH. 40 PC • •• �'. :• PeOstone LEACHING C1 C y SCALE:1'=10' ..w .: -r LOAMY SAND No. 216 60 CRUSHED - Slope - 0.005 min 10 YR 6 6 N .. STONE » / MEDIUM SAND 9 ci � � REV. DATE: REMARKS DATE: 10/19/2001 56 s 10 YR F00TINc _ . . . 4 ,r C 7/ C _ m �y•p' •L:.'t.ii: •:.!%'p►•. .•..•• p. ..v^y" P-\, 6p 6 4 ss ' 1- 10 26 01 Revise House C2MEDIUM SAND 7/Z7 200 f - 2- 04 16 04 Revise House do Drive } 2.5 Y 6/4 M - 3- 20 04 Revise House 0�1 � 120 120 - 4- 07,1131019 Rev. House do Serr tic o NO WATER NO WATER ENCOUNTERED - 5- 07 0 09 Locate Fence & Path - 6- 1 9 d d imensi ns 1500 GALLON SEPTIC TANK DISTRIBUTION BOX 5' MfN RATE- <2 MIN/IN (EL 5.6) EVEL o TO BE INSTALLED ON A L STABLE BASE TO BE INSTALLED ON A LEVU STABLE BASE OIMM MMER N0 Groundwater obeervea o EL. 5.6 0: 2001 2001-74 surve worksht 2001074se ticl-rev8.dw CULTECO RECHARGER 330 N JOB 2001-074 ---------------- i