HomeMy WebLinkAbout0110 IRVING AVENUE - Health 110 Irving Avenue
Hyannis
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SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) �, (size)
NO.OF BEDROOMS 5—
OWNER i9V
PERMIT DATE: C( M4;i� DATE:N
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
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TOWN>OF BARNSTABLE
LOCATION SEWAGE#
VILLAGE a t! quo ASSESSOR'S MAP&PARCEL
INffAttErlk'S NAME&PHONE NO. �.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)C-6&wz,4kd '7
NO.OF BEDROOMS
OWNER /IIQQiA —fiS/QF�
PERMIT DATE: 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
Page to of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Praperq Address: 710 Irvin Avenue i
yannisoort
Owuer. Timothy Shay
Date of Impcetio t:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks ar
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
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Commonwealth of Massachusetts
ae7-/38
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 0
110 Irving Ave. r.
Property Address
Roache
Owner information Owner's Name r
is required for every page. HY P annis ort MA 02601 4/4/19 + ''
Cityrrown State Zip Code Date of Inspection }
Q3
Inspection results must be submitted on this form. Inspection forms may not be altered in any,
way. Please see completeness checklist at the end of the form.
A. General Information 6&W i 39-+8
1. Inspector:
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 I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4/4/19
Inspect ignatu 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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 4/4/19
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated ale
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 4/4/19
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 110 Irving Ave.
Property Address
Roache
Owner information Owners Name
is required for every page. Hy p annis ort MA 02601 4/4/19
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 4/4/19
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 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.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 4/4/19
Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
El ® 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 5 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for every page. HY P annis ort MA 02601 4/4/19
City(rown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Seasonal
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:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 4/4/19
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
No recent pumping per owner
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 4/4/19
C4rrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2003 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
18"
Depth below grade: 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.):
Septic Tank(locate on site plan):
12"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
H-10 1500g septic tank appears to be structurally sound
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1500g
Dimensions:
Sludge depth:
3"
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
GN 110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for p
every page. y H annis ort MA 02601 4/4/19
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle '12
Scum thickness trace-1/2"
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
>2"
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 3 years to prolong the life of the system
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 4/4/19
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 4/4/19
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box 20" below grade and in very good condition
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 4/4/19
Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4
❑ 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.):
Chambers were video inspected and are dry at this time, No indication of past hydraulic failure, top of
chambers is 26" below grade
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 4/4/19
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 4/4/19
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
R
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GG
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43
lv
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
a r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for H annis ort MA 02601 4/4/19
every page. y p
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
>12'
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 Ian reviewed: 2003 NGW 144"
g p Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
4' seperation per 2003 compliance
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping The site is 23'msl and nearby surface water is at 5'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.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 110 Irving Ave.
Property Address
Roache
Owner information Owner's Name
is required for every page. Hy p annis ort MA 02601 4/4/19
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
S
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 110 Irving Avenue
1iyannisport o
Owner's Name: Ti mnth)z Sh y
Owner's Address: 214 rroAn Street
Date of Inspection: "a
Name of Inspector:(please print)W i 11 iam E Rob i nson S r.
Company Name: William E. Robinson Septic Service
Mailing Address: P 0 Box 1089
Centerville, MA
Telephone Number:_i 5 0 81 7 7 S-g 7 7 6.
-CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and thatthe information reported.
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems:I am a D:EP
approved system inspector pursuant to Section 15340 of Title 5(310 CMR15.000). The system:
,
`'' Passes
Conditionally Passes r
Needs Further Evaluation by the Local Approving Authority ,
Fails_
Inspector's Signature: � Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health-4
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design Qow 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 seat to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
s
Page 2 of I I ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 1 0 Irving Avenue
Hyannisport
Owner: Timoth Sha
Dale of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys m Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
reps' d.The system.upon completion
Y P p on of the replacement or repair,as a roved b the Boar PP Y d of Health,will pass.
Answe yes,no or not determined Y N ND in the
( � ) for the following statements.if `n ��e g of determined please
xplain P
e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsoun ,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 me I septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicati g that the tank is less than 20 years old is available.
ND ex lain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstru ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
IN.Dexplain:
al of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than 4 tunes a year due to broken or obstrt-ctcd pipe(s).The system will
pa's' inspection if(with approval of the Board of Health):
broken pipes)are replaced
obstruction is stmovod
ND c plain:
Page 3 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY AASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 1 0 Irving Avenue
Hyannisport
Owner: Timothy Sha
Date of Inspection:
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 fail' g to protect public health,safety or the environment.
1. ystem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
ystem 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
sys em 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
_ y rn has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front 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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 1 0 Irving Avenue
Hyannisport
Owner: Timothv Shay
Date of Inspection: rf�l—
D. Sy lem Failure Criteria applicable to all systems:
You mu t indicate`Yes".or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than day[low
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 I00.feet of a surface water supply or tributary to a surface
water supply.
Any portion of.a cesspool or privy is within a Zone 1 of a.public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well:
Any portion of a cesspool or privy is less than 100 feet but greater than 50 f ct from a private water
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds
indicates that the well is free.from pollution from that facility and the presence or ammonia
nitrogen and nitrate nitrogen is equal to or less than S ppm, provided that no other failure criteria
are triggered.A copy of the analysis must be attached to.this forma
(Yes/No)The system fails. I have determined that one or more of.the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E: Large Systems:
To a considered a large system the system must serve a facility with a design-flow of 10;000 gpd to 15,000
gpd•
You ust indicate either"yes"or"no"to each of the following:
(The ollowing criteria apply to large systems in addition to the criteria above)
yes o
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you hav, answered"yes"to any question in Sectim E the system is considered a significant threat,or answered .
..yes"in Se tion D above the large system has failed.The owner or operator of arty large system considered a
significant t eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system oNvner should contact the appropriate regional office of the Department.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B _
CHECKLIST
Property Address: 1 1 0 Irving Avenue
Hvannisport
Owner: jimc)thy Sha
Date of Inspection:
Check if the following have been done.You must indicate`'yes"or"no"as to each of the following:
Yes No /
1/Pumping information was provided by the owner,occupant,or Board of Health
v 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)
T Was the facility or dwelling inspected for signs of sewage back up?
v — Was the site inspected for signs of break out?
— Were all system components,excluding the SAS,located on site?
v 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 Y
disposal systems?
P
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no /
/�Existing information.For example,a plan at the Board of Health.
Determined in the field(if an of the failure criteria related to Part C i a 'Y s t issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)j
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 1 0 Irving Avenue
Hyannisport
Owner: Timothx Shay
Date of Inspection: 25 !,7-1 0 t;
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): �J-�"ber of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x a of bedrooms): 7 C�
Number of current residents:
Does residence have a garbage grinder(yes or no): A-o
Is laundry on a separate sewage system(yes or no): if yes separate inspection required]
Laundry system inspected(yes or no):2A
Seasonal use:(yes or no): �
Water meter readings,if available(last 2 years usage(gpd)): 0 4/0 5 - 73, 500
Sump pump(yes or no): 4 U — 119, 505
Last date of occupancy: /9, 1•-v
COMMERC L1INDUSTRIAL
Type of estab ishment:
Design flow based on 310 CMR 15.203): and
Basis of de ign flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):—
Industrial aste holding tank present(yes or no):—
Non-sang waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of.occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: �4the
Was system pumped as part ospection(yes or no):
If yes,volume pumped:_gallons—How was quantity pumped determined?
Reason for pumping:
TYP�F 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)
_Tight tank Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components,date installed(if known)and source of information:
7 2 v 3
Were sewage odors detected when arriving at the site(yes or no): Ili U
6
I
Vjgc 7 of I I
OFFICIAL INSPECTION F0101-NOT FOR VOLUNTARY ASSESSNIM'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F0101
PART C
SYSTEM INF0ULATION (continued)
Properly Address: .1 1 0 Irving Avenue
Hyannis port
Owner: -Timothy Shay
Date of Inspitolon:
BUILDING LIVEN(locate on site plan)
Dcpdt bcl w grade;
hlaterials of construction:_cast iron _40 PVC_Quiet(explain):
Distance (roil►private seater supply tccll ur suction line:_
Coln is(oil condition of juutts,venting,evidence of leakage,cic.):
SEPTIC TANK; t/
_._.(Ivcatc on site plan)
Lr
Depth below grade:
Material of construction: kIlUcic—metal—
fiberglass pulyedlytene
_othcr(cxplain)
1fLink is meta)list age:_ is age cunfumcd-by a Certificat
Certificate) e u(Cungrliance(y n
es or u):_(atiach a copy of
y
Dimensions:_(� w _�
Sludge depth: `/ 5
Dislance from lop of sludge Io bonunt of outlet ace or bafllc: - 3
Scum thickness:J —3
Distance from tup of scum to lup of outlet Ice or bafllc: ,
Distance born bultum of scum to bottom of inlet tee or battle:
lose were dimensions dcicnnincd: 0 Mi-- L®,,o, a 3
Cumnrents(oil pumping recommendations, inlet and outlet lee ur bafllc condition, structwal inte6rity,liquid Ics•cls
as related to oullcl u►vert,evidence of leakage etc.):
GREASE T1 ':_(locate oil site plan)
Depth below ade:_
Material of c nslrucliun:—concrete Inctal fibuglass_pulycillylcnc _other
(captain): --
Dimensions
Scum Chic less:
Distance onl lop of scum to lop of uutict Ice or bafllc:_
Distance on►buttum of scum to buitunl of outlet tee or baffle:
Date of asl pumping:
Co nun nls(oil pumping leconunendatiuns, inlet and outlet(cc or bafllc cunditiu;I,stluctulal integrity,liquid Ic%-CI,
as rcla;.cd lu oullcl inval,ct-idcn(c of Icaka fc,cic.):
7
)'age 8 of I 1
OFFICIAL INSPECTION FORM — NOT FOIE VOLUNTARY ASSENSIIIENTS
SUUSUIU�ACL SENVAU DISPOSAL SYSTEM INSPEICI'ION FORM
PART IC
SYSTM 1NFO11111A,ric N(continued)
Property Address: 1 1 0 Irving Avenue
Nvannisport
Owner:
Date of lospcctlou; — �6-�
TIGHT r IIOLULNG TANK:_(tardc nsust be pungreJ at Iiine of inspection)(locate on site plan)
Depth be ow grade:
hlalcrial f construction:__concrete____metal_libctglass rirlycthylcnc_othcr(explain):
Unit, ons:
CapacIt allons
Design flow; gallons/Jay
Alarm present(yes ur no):
Alai level; Alann in wurkin• order
Date f la
pumping: 6 (Jcs or nu):_
Cull r cnts(condition of al arm and float switches,etc.):
DISTRIBUTION BOX:_(i f lltcscn(must be opcncd)(locate on site plan)
Depth of liquid level above outlet invert: C9
leka (nose if box is Icvc1 and distribution
leakage
tv outlets equal,any evidence of solids carr)•over,any evidence of
yc into or out of box,cic.):
1'UMI'CII/_(locate on site plan)
Pumps in�eer(yes or nv):Alanns in%% der(yes or no):Comments ition of pump chaurber,condition of pumps and appurtenances,etc,):
Page 9 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 1 0 Irving Avenue
Hyannisport
Owner: Timothy Shay
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): /(locate on site plan,excavation not required)
If SAS not located explain why.
Type
teaching 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.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and con guration:
Depth—top of li uid to inlet invert:
Depth of solids ayer:
Depth of scum ayer:
Dimensions o cesspool:
Materials of onstruction:
Indication o groundwater inflow(yes or no):
Comments note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:/(notne
ate on site plan)
Materialsuction:
Dimensio
Depth of
Commetlondition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 110 Irving Avenue
Hyannisport
Owner: Timothy Shay
Date of Inspection:
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.
) ! O
e�
l3/*
� >3
1 •
i
z
A-3 v1 b
31
�J
04 . `13
5-3 �L
110
ge 11 of 11
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addr ess: 110 Irving Avenue
_Hyannisport
Owner. Timothy Shay
'Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 49 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
served site(abutting property/observation hole within 150 feet of SAS)
Necked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You musl,describe how you establi hed the high ground water elevation:
11
f
TOWN OF BARNSTABLE 1�G
LOCATION fLLJ i JIQ A VC
SEWAGE
VILLAGE ASSESSOR'S MAP& LoT2121 131
INSTALLER'S NAME&PHONE NO. �C� '�,4�, �: ^j 7 �� $✓) 7 e
SEPTIC TANK CAPACITY .
i LEACHING FACILITY: (type) L r ,.. -�'I(si e) 2.3
NO.Of BEDROOMS S"
BUILDER-OR OWNER
PERMITDATE: f - �-4.3 - Y COMPLIANCE DATE:%/ i'7—03
Separation Distance Between the:
Maximum Adjusted Groundwater Tabf Leaching Facility ; Feet
Private Water Supply Well and Leachany wells existon site or within 200 feet of leachi Feet
Edge of Wetland and Leaching Facilids exist
Within 300 feet of leaching facility Feet
Furnished by.
'r✓ AIA
r
Commonwealth of Massachusetts!
Title 5 Official Inspection Form
s Subsurface Sewage.Disposal System Form - Not.for Voluntary Assessments
110 Irving Ave T,
Property Address
David Roache
Owner Owner's Name
information is
required for Hyannisport MA 02647 April 30,
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. Please see completeness checklist at the end of the form.
Important: A. General, Information - /1
When filling out
forms on the
computer,use 1. Inspector. f
only the tab key
to move your Patrick M. O'Connell _
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.
Company Name
r� 189 Cammett Road
Company Address
Marstons Mills MA 02648
City/Town State Zip Code
508-428-1779 SI 12855
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 maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Sm ion 15.340. of
Title 5 (310 CMR 15.000). The system: _
® Passes ❑ Conditionally Passes ❑ Falls w
❑ Needs Further Evaluation by the Local Approving Authority Cl
( •
I t u0 `r
April 30, 2012 Job# 12-70
I spector's Signature Date :'' r--1
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.
!Sins-11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 1 of 17
V
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
x Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
110 Irving Ave
Property Address
David Roache
Owner Owner's Name
information is
required for Hyannisport MA 02647 April 30, 2012
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Recommend pumping tank. Leaching chambers were empty with no sidewall stains.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 Irving Ave
Property Address
David Roache
Owner Owner's Name
information is H annis ort MA 02647 April 30, 2012
required for y p
every page. City(Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
" ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if ,
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
• 15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 Irving Ave
Property Address
Qavid Roache
Owner Owners Name
information is
required for Hyannis port MA 02647 April 30, 2012
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑' The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
A ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance: .
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
l5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title- 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 Irving Ave
Property Address
David Roache
Owner Owner's Name
information is
required for Hyannisport MA 02647 April 30, 2012
every page. CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department. ,
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 110 Irving Ave
Property Address
David Roache
Owner Owner's Name
information is H annis Ort
required for Y p MA 02647 April 30, 2012
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 '
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?
r® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
#. Number of bedrooms�(design): 5 Number of bedrooms (actual): 5
n
DESIGN flow based on 310 CMR 15.203 example:for9p 550
110 d x#of bedrooms(t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
110 Irving Ave
Property Address
David Roache
Owner Owner's Name
information is
required for Hyannisport MA 02647 April 30, 2012
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage s stem?[if yes separate inspection re
quired] El Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d N/A irrigation
i 9 A ( Y 9 (gP )) system.
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: UnknownDate
Commercia III ndustriai 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:
t5ins•-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
vim
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 110 Irving Ave
Property Address
David Roache
Owner Owner's Name
information is
required for Hyannisport MA 02647 April 30, 2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: None
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons;
How was quantity pumped determined?
Reason for pumping:
Type of System: ,
® Septic tank, distribution box, soil absorption system
❑ Single cesspool -
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
f
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 Irving Ave
Property Address
David Roache
Owner Owner's Name
information is
required for Hyannis port MA 02647 April 30, 2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
System installed: 11/7/03
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 1
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: 10.5' long x 5.8'wide- 1500 gal.
Sludge depth: 3
15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 110 Irving Ave
Property Address
David Roache
Owner Owner's Name
information is
required for Hyannisport MA 02647 April 30, 2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness 3
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 10.1
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.):
Liquid level was found at bottom of outlet invert and tees were intact. Observed trace of solids in
outlet tee, recommend pumping.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
-Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 o1 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
110 Irving Ave
Property Address
David Roache
Owner Owner's Name
information is H annis ort
required for Y P MA 02647 April 30, 2012
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.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
'Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: date
Comments (condition of alarm and float switches, etc.):
Y ' 1
Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 Irving Ave
Property Address
David Roache
Owner Owner's Name
information is
required for Hyannisport MA 02647 April 30, 2012
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
No solids or high stains present. Liquid level was at bottom of outlet pipes.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
'If SAS not located, explain why:
P i i
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
110 Irving Ave
Property Address
David Roache
Owner Owner's Name
information is
required for Hyannisport MA 02647 April 30, 2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: Four 500 galdrywelts.
❑ 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.):
leaching chambers were empty at time of inspection no sidewall stains were observed
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 r
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 5
Commonwealth of Massachusetts
Title 5 ffi O cial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 Irving Ave
Property Address
David Roache .
Owner Owner's Name
information is H annis ort MA 02647 April 30, 2012
required for y P P
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):'
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 Irving Ave
Property Address
David Roache
— -- .._..............__..... --- -- ----
Owner Owner' Name
information is H an nis ort MA 02647 A nl 30, 2012
requiredfor �_._.___ p.._.-...._....._______....___..-----.:.._..---...- P
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
. r
! r'r'f / r • / ! / /
9 31
3 43
\4 0 47
0094
♦ ♦ \ ♦ ♦ , \ ♦ \ \
i{ 1
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°w 110 Irving Ave
Property Address
David Roache
Owner Owner's Name
information is
required for Hyahnisport MA 02647 April 30, 2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 10+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you establish3d the high ground water elevation:
Perc test performed prior to repair found no water at 10 feet.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
fi
Y'\ r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 Irving Ave
Property Address
David Roache
Owner Owner's Name
information is H annis Ort
required for Y p MA 02647 April 30, 2012
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Skeich of Sewage Disposal System either dawn on page 15 or attached in separate file
F
a t.
15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BARNSTABLE GL
LOCA.1 ION J 16 3 �2 �UL C� A VC SEWAGE # 6 �.Z
VILLAGE /Iy 16 2 14 yAVl yl l ASSESSOR'S MAP& LOT 9 FT 13Y
INSTALLER'S NAME&PHONE NO. `�a.1S
SEPTIC TANK CAPACITY9
�- S.--- 2.
LEACHING FACILITY: (type) �+ (si ) -
NO.OF BEDROOMS
BUILDER OR OWNER es
PERMTTDATE://-`� —0 3 COMPLIANCE DATE://"',~-4�
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Botto f Leaching Facility Feet
Private Water Supply Well and Leaching Facili J (If any wells exist
on site or within 200 feet of leaching facili ) Feet
Edge of Wetland and Leaching Facility(If y wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
- - 5
,2 3 {
�{'�
r
�s
cr
�� � �I
8 � w
1"" w
� �' � �
��.
�_�
Q.�i
i
.��
:�x-T
'�
Fee &0_
• r:
THE COMMONWEALTH OF MASSACHUSETTS Entered in compute
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pprication for Mi5pogal bpztem Congtruction Permit
Application for a Permit to Construct( )Repair(x )Upgrade( )Abandon( ) ❑Complete System 0 Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
1sess10vn Ave Hyannisport Arthur Cook
Asor's ap az
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
W.E. Robinson Septic Service C:R. Short
P.O. Box 1089 Centerville P.O. Box 1044 S. Dennis
Type of Building:
Dwelling No.of Bedrooms ] Lot Size sq.ft. Garbage Grinder(n�
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow b�� gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank J Type of S.A.S. v is
Description of Soil, r• v✓ I- ✓k\-C -
Nature of Repairs or Alterations(Answer when applicable)
septic system. ♦ o plans of C R Short RI-a.n #01-0995
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B d Health.
Si ned Date)/�t`�
Application Approved b Date .3
Application Disapproved for the following reasons
Permit No. __5 2�:9. Date Issued l 3 O
Fee 5
° THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
:2�/
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
a ;Ippricatton.for Miopaal *vztem Conotructton Permit
Application for a Permit to Construct( . )Repair(x)Upgrade( )Abandon( j ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
119-= Vinq Ave Hyannisport Axthur Cook
Assessor's ap/P,,el'
Q
Installer's'Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
_ -W.E. Robinson Septic Service..; CCR. Short
P.O. Box 1089 Centerville P.O. Box 1044 S. Dennis
Type of Building:
DwellingNo.of Bedrooms '� � Lot Size sq.ft. Garbage Grinder(nd A
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �y gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title t -
Size of Septic Tank C u ,
p , r J Type of S.A.S. y 1 �o -u z-�
Description'of Soil r✓,/,PC"
Nature of Repairs or Alterations(Answer when applicable) install: Reif Title c
Septic Syst;oyt�_i-�r+lans of C_ R Short Plan 901--998 J
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
4. in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board�ffHea�lth. j
.. Si ned � 1.�+,n_: . Date140:2t
w Application Approved by Date G 3
Application+Disapproved for the following reasons
Permit No. Date Issued' / 3 0
_. ._._._ ----------
Cook THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Comphattce
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( x)Upgraded( )
Abandoned( j by W.E. Robinson Septic Service
at 1 1 0 Irving Ave Hyannisport has been construct Yl ip accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.1- SZ9 dated 11 3 03
Installer Designer A
The issuance of s permit shall not be construed as a.guarantee that the syil function rdesigned
Date ` I.-7 s m w
I U Inspector
f
No. �J.. SaG!� ----------Fee 50. _ _
Cook THE COMMONWEALTH.OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Migoar *pztem Con5tructton Permit
Permission is hereby granted to Construct( )Repair(x)Upgrade( )Abandon( )
System located at 1 1 0 Irving Ave Hyannisport
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:Constructio must be completed within three years of the-date f.this p t.
Date: 173�� 3 Approved by
BENCHMARK
TOP OF FOUNDATION 20 FT- MINIMUM FROM CELLAR SOIL TEST
100.00 10 FT. MINIMUM FROM SLAB OR CRAWL SPACE
DATE OF SOIL TEST t0.j7L03
ELEV. _ _ _ i 10 FT. MINIMUM __
(ASSUMED) I CONCRETE CLEAN SAND WITNESSED BY E_ E•ARQ@Jt�
COVERS LOAM AND SEED OBSERVATION HOLE 1 ELEV.=__98.2_
4" SCHEDULE 40 PVC PIPE
`- MIN. PITCH 1/8" PER FT. PERCOLATION RATE _< 2 MIN./INCH AT 84 INCHES
2" LAYER OF
1/8" TO 1/2" LEGEND: DEPTH HORIZ TEXTURE COLOR MOTT. OTHER
99.25 MAX. WASHED STONE EXISTING SPOT ELEVATION 00,�0
2.5' 4" CAST IRON PIPE 9.`5 MIN. EXISTING CONTOUR ----00----
(OR EQUAL) MINIMUM x FINAL SPOT ELEVATION 0-23 LOAMY SAND 10YR3 2 NO uMRIAL
PITCH 1/4" PER FT. < z FINAL CONTOUR
ZABEL FILTER-,, SOIL TEST LOCATION UNS (TABgLE
FLOW LINE 6. � UTILITY POLE -o- 23-33 LOAMY SAND 10YR4 6 NO MAYtRIAL
PLUMBING TO B£ RAISED 101 TOWN WATER -W W
ELEV. 97.5 MIN ° ° ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ CATCH BASIN �� �g
AND RE-PIPED BY A ELEV. _ _96•25_ 2 O ° ° ° GAS LINE \"� 33-45' Ct LOAMY SAND 2.5Y8 4 NO MATETRIA�
LICENSED PLUMBERAS -- LEVEL ° ° ❑ ❑ ❑ ❑ ❑ ❑ ❑ O ❑ ❑ ❑
NEEDED ELEV. _ _96.5 GAS ELEV. = 96.00 - 6" SUMP ELEV. _ _95.80_ ° ° CLEAN OUT C
BAFFLE - °° °° ❑ ❑ ❑ Cl ❑ ❑ 01 ❑ ❑ ❑ ❑ ° 2' ° CESSPOOL C.P. O Vp�Y UNS!>,ITABLE
DISTRIBUTION - ° ° ° ° ° 45-84 C FlNE SAND 2.5Y6 4 NO MA RIA
ELEV. - ❑ ❑ ❑ ❑ ❑ ❑ ❑I ❑ ❑ ❑ ❑ _ 93.50
LIQUID OUTLET BOX - _ ° °° ° ° ° ° ELEV. - __--_-
DEPTH TEE 4 FEET 14 INCHES (TO BE PLACED ON FIRM BASE) TO BE WATER TESTED 84-1M' 3 COARSE SAN01 10YR5 4 NO
5 FEET 19 INCHES IF MORE THAN ONE OUTLET 4-500 GALLON DRYWE'LLS WITH STON-
-7
6 FEET 24 INCHES 1500 GALLON
7 FEET 29 INCHES (TO BE PLACED ON FIRM BASE) IN AN 13' X 42' X 2' TRENCH FORMfT/ON z 6 3' WELL N/A NO WATER ENCOUNTERED AT __12__ ELEV. _ __QZ2_ i
8 FEET 34 INCHES SEPTIC TANK ZONE
3/4" TO 1 1/2" CLEAN SOIL ABSORPTION INDEX
DOUBLE WASHED STONE ADJUST&Z DESIGN CALCULATIONS
FREE OF FINES & SILT SYSTEM (SAS) NUMBER OF BEDROOMS -5___
USGS PROBABLE WATER TABLE ELEV. = _j�,(A_ GARBAGE DISPOSAL UNIT NO. N01-ALLOWED
SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATER TABLE ( / / ) ELEV. = _N_/A_ TOTAL ESTIMATED FLOW
NOT TO SCALE BOTTOM OF TEST HOLE ELEV. _ _� .�_ (110 GAL.,/SIRIVAYX `L SR.) _55Q_ GAL.%DAY
REQUIRED SEP77C TANK CAPACITY _15M_ GAL.
ACTUAL SEPTIC TANK CAPACITY -15Q0_ GAL.
SOIL CLASSIFCA77ON -1__
DESIGN PERCOLA 77ON RA TE <5 - M/N.//NCH
EFFL UEN T L OADING RA TE _DJA_ GAL./bA Y`S.F.
LEACHING AREA �766- SO. FT.
(13'x42')+(l'10'x2')
LEACHING CAPACITY _569_ CAL./DAY
766 X 0.74
RESERVE LEACHING CAPACITY N JA_ GAL./DA Y
I NOTES:
1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P.
TITLE 5 AND THE TOWN RULES AND REGULATIONS FOR THE SUBSURFACE
DISPOSAL OF SEWAGE.
2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO
. 99.9 >>B.g? WITHIN 6" OF FINISHED GRADE.
- _ 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF
1 BEDROOM - WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN
EXISTING - 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE
I
GARAGE N _ _ g8.7 LSED UNDER OR WITHIN 10 FT, OF DRIVES OR PARKING AREAS.T.D.F.= i _ 4. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL
99.0 BE MORTARED IN PLACE.
10030 99.4 42'_-_'__g_ /� SHED 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH
MIN. xA.S "�: .5 DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT IS TO
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
99.6 5 22' Ca ( 0 i 6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR
IS TO CALL "DIG-SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS
- PRIOR TO COMMENCING WORK ON SITE.
•-9�4 in ��~� / 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS
d. 30't SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. ANY VARIATION
EPTIC IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER
SEE NOTE , 6 TANK �� 99 1 IMMEDIATELY.
' 98.9 8. PARCEL IS IN FLOOD ZONE _ C
9. LOT IS SHOWN ON ASSESSORS MAP __9k AS PARCEL - 138
M 10. ALL UNSUITABLE MATERIAL SHALL BE REMOVED FROM UNDER, AND
A FOR .A MINIMUM OF 5 FEET FROM AROUND THE SOIL ABSORPTION SYSTEM,
AND BE REPLACED WITH SAND AS SPECIFIED IN 310 CMR 15.255- (3)
` 99.3 (I.E. TITLE 5) IF ENCOUNTERED BELOW S.A.S. PIPE INVERT.
V.2 BH. i ? . 11. EXISTING SEPTIC SYSTEM TO BE PUMPED AND FILLED WITH SAND OR REMOVED.
' 12. A ZABEL A1800 FILTER IS TO BE INSTALLED.
99.4 13. CONTRACTOR TO PROVIDE SHORING AS NEEDED TO PROTECT BUILDING
y. AND PROPERTY LINE,
4 BEDROOM 4 APPROVED:P V BOARD F HEALTH
�J RO ED BO D 0
EXISTING 99.5 4
DNELLING .r
T.O.F=
100.00
+ - r,4f&31 J#2525 TE AGENT
PORCH ; PROPOSED SEPTIC DESIGN)
99.6o_ _ - - J 99.6 FOR
• 99.5 CRA/G�7 WM. E. ROBINSON SR./COOK
99.3 ROAD ACh
• 99.2 LOC.
110 IRVING AVENUE ^�
N A BARNSTABLE, MASS.
x 99.3 LOT AREA
104.Zg' 14,4B0 t S.F. A
I 5 � _
x MAS CREG R. SHORT, P.E.
235 GREAT WESTERN ROAD
ss.8 0 508- P. 0. BOX 1044
r 98.6 a r 398-831"' SOUTH DENNIS, MASS. 02660
73
/R VIAIC A VE-VU�- cods _ - _
�rR�N� a`� DATE OCT 23, 2003 1 1 SCALE 1 " = 20'
I
REV. JOB NO. 01 _0995
I i i
LOCATION MAP SHEET 1 OF 1
01-0995 R CooK.dwg 02003 CRAIG R. SHORT, P.E.