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HomeMy WebLinkAbout0098 ISALENE STREET - Health 1 98 Isalene Street Hyannis A= 267-042 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^ 98 Isalene Road u Property Address Karl & Sharon Heston Owner Owner's Name information is H annis ort / required for every Y p ✓ MA 02647 7/29/2020 page. Cityrrown 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:when filling out forms A. Inspector Information 61# /40'a:� on the computer, use only the tab James Ford key to move your Name of Inspector cursor-do not Ford Septic Services, LLC use the return Company Name key. P.O. Box 49 rae Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further aluation by the Local Approving Authority 4. ❑ Fails 8/4/2020 YInsper'sature Date nsp ctor 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 Y P 9 p Y 9 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c !% 98 Isalene Road V� Property Address Karl & Sharon Heston Owner Owner's Name information is required for every Hy p annis ort MA 02647 7/29/2020 — page. CityFrown 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 98 Isalene Road V Property Address Karl &Sharon Heston Owner Owner's Name information is required for every Hyannisport MA 02647 7/29/2020 page. Cityrrown 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form `a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v— 98 Isalene Road Property Address Karl & Sharon Heston Owner Owner's Name information is H annis required for every poi MA 02647 7/29/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ; J 98 Isalene Road Property Address Karl & Sharon Heston Owner Owner's Name information is required for every Hy p annis ort MA 02647 7/29/2020 page. Cityrrown 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 t5insp doc-rev.7/2 612 01 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 v Commonwealth of Massachusetts } Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 98 Isalene Road Property Address Karl & Sharon Heston Owner Owner's Name information is required for every Hyannisport MA 02647 7/29/2020 page. City/Town 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 4 p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�� e 98 Isalene Road u- Property Address Karl & Sharon Heston Owner Owner's Name information is required for every Hyannisport MA 02647 7/29/2020 page. City/Town 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Isalene Road U Property Address Karl & Sharon Heston Owner Owner's Name information is required for every Hyannisport MA 02647 7/29/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow_(seats/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: Unknown Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Reason for pumping: maintenance t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Isalene Road Property Address Karl & Sharon Heston Owner Owner's Name information is required for every Hyannisport MA 02647 7/29/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ 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: 6/3/2011 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 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 F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 98 Isalene Road Property Address Karl & Sharon Heston Owner Owner's Name information is H annis ort required for every Y p MA 02647 7/29/2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 21 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 15 How were dimensions determined? measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The Tee's were present. There was no sign of leaks e. The tank was pumped after the inspection l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 98 Isalene Road Property Address Karl & Sharon Heston Owner Owner's Name information is required for every f yannisport MA 02647 7/29/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): N/a 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 y ❑ other(explain): N/a 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 I - Commonwealth of Massachusetts �e I? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Isalene Road Property Address Karl & Sharon Heston Owner Owner's Name information is required for every Hyannisport MA 02647 7/29/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): N/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Even 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.): The D-box was normal and no solids were present The cover was at 12" t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 98 Isalene Road Property Address Karl & Sharon Heston Owner Owner's Name information is required for every H yannlS O p rt MA 02647 7/29/2020 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.): n/a * 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: El leaching galleries number: ® leaching trenches number, length: 3- rows of 8quick 4. 32'x8.50' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Isalene Road Property Address Karl & Sharon Heston Owner Owner's Name information is H annisport required for every y MA 02647 7/29/2020 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.): ` The SAS was dry_and clean. There was no sign of failure. A camera was used 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.): n/a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form FI, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Isalene Road Property Address Karl & Sharon Heston Owner Owner's Name information is required for every Hyannisport MA 02647 7/29/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: N/a 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Isalene Road Property Address Karl & Sharon Heston Owner Owner's Name required for is every H anniS ort required for eve y p MA 02647 7/29/2020 page. City/Town 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 r � Q v 3A�k Ae . Q a O 30 A Q a 33 6 3 31 33 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .......... 98 Isalene Road V Property Address Karl & Sharon Heston Owner Owner's Name information is required for every Hyannisport MA 02647 7/29/2020 page. CitylTown 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: 25'+/- 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: Topo and water contours mapd ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: 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 r r Commonwealth of Massachusetts� tts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u � 98 Isalene Road Property Address Karl & Sharon Heston Owner Owner's Name required for is every Hyannisport required for eve MA 02647 7/29/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of p pp 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 No. / .0 r Fee A G THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS es RppliLAtlon for Misposal 6p4tem Construction permit Application for a Permit to Construct(44' Repair( Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No.qg ,Zj&_f.=/v;c-:, ,S'rrozi,r Owner's N e,Address,and Tel.No. Assessor's Map/Parcel ', O 1/14 In taller's Name Address,and Tel.No. S0 9-2$D-7 75-9 Designer's Name,Address,and Tel.No.,S"O - 36 /q 9/ C s4syl�Lj-e !2� !W , 0Wi/l I /V 12 r G 0 .r�dJ�u/rAA Type of Building: ' %,k^ -Ur1y ►p �Idw/1 7_0,1 ,- A z M«� 3 gectroe�hj, n.- .S 9 l/ Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 —0 gpd Design flow provided -3 � gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �'`/s1-4-11 0_91yX 2y Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. S' d _ffDate Application Approved by 7ff fLr Date o2 f Application Disapproved by Date for the following reasons Permit No. �� �� �/(p d Date Issued 2 2l� No. 201 0 Fee / U THE COMMONWEALTH OF MASSACHUSETTS-.',,"., Entered in computer: // PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MAS -C,HUSETTS 2pplication for jBisposir,' Item (Construction Permit Application for a Permit to Construct(,�, ' Repair( 4—Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. q _rS'/9L 57'rO/2 r . Owner's Na e,Address,and Tel.No. Assessor's Map/Parcel ( 7, U�l4 ��'i/ra /.J 14S k Installer's Name,Address,and Tel.No. SO 200 7 7-5-2 Designer's Name,Address,and Tel.No. Jos eloA /J� '`'�"``J' l_ � ,s; S UY�/i y r%vc - / L��� /l � API A /y/ /2 T G 14 �H cvrclii p Type of Building: U,k- -Up i,A A IOwe Z,ones !�✓'Or`^o �`L spP�lUo hl �� ay�� x Dwelling No.of Bedrooms Lot Size sq.'ft. Garbage Grinder( ) Other Type of Building No.of Persons `41;�„Showers( ) Cafeteria( ) r Other Fixtures Z, „ Design Flow(min.required) 73730 gpd Design flow provided � ✓5 c gpd Plan Date Number of sheets M;; Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /r1-l4TOY Date last inspected: Agreement: The undersigned agrees to ensure the,construction and maintenance of the afore described on-site sewage disposal system in i »., J s accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed i �� r ��,2iLdJ/ Date Application Approved by I /Z Date < d? // Application Disapproved by Date for the following reasons Permit No. p 0 Date Issued — c/ .2// ;'-_--------- ------------ ---------- ---- - - ------ --- -- --------- ------------------------------------------- `�_ :. THE COMMONWEALTH OF MASSACHUSETTS a BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired( L) Upgraded( ) Abandoned( )by at %d i s 14L I Ni_= S rvi,ET' HY� <i S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2 O dated Installer Jos elo� l2-e Z�14 ,-,2 Designer #bedrooms j Approved desi n flow gpd i The issuance of this pe i sha not be construed as a guarantee that the syste funcm ill ' n de,ig ed. Date Inspector No. p 0 I A 0 Fee A G THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstrm Construction Permit Permission is hereby granted to Construct(L) Repair Upgrade( ) Abandon( ) System located at / and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructi n must'be completed within three years of the date of this permit. Date J/ Approved by f I Town of Barnstable FZHE 1pk,O Regulatory Services T Thomas F. Geiler, Director • BA"9rAB1B. MASS. Public Health Division 039. prf0 Mp$► Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: r a L` S �U� `'WL Installer: Designer: �l)�Y� � � G l Address: Address: 6( 4a✓��=T '6?4^4ACq A1Y1- Y�1 4(L r%) )s n l t c S OZAI? X On G E ��kLqoS was issued a permit to install a (date) / (installer) septic system at `�Cg � �' ST based on a design drawn by (address) :!:;?I,JNy)—ID. --LA,1AG-(L_U4 TP, dated �'A V� t�� 2010 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic stem but in accordance with State & Local Regulations. Plan revision or P system) 8'u certified as-built by designer to follow. N OF MAS`�C �/ DAVID D. (Installer's Signature) FIAHERTY, JR. No. 1211 r CIS Elk sgN17AF0 '-(Designer's Si atur fix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC FfkALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTI61 THIS FORM AND AS- BUILT-CARD ARE RECEIVED BY THE BARNSTABLE PLT9LIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form Town of Barnstable r# 30 25'- ,�Y� Department of Regulatory Services MUMSTABLA : Public Health Division Date 7A.) A) �pi6so. ,e� 200 Main Street,Hyannis MA 02601 rED Date Scheduled -4. l Time- lv Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed By; i LOCATION& GENERAL INFORMATION Location Address ov, T.46EV&--,_ Owner's Name,�}t/��f y�Z W40f f�41 �F/!//U/s < f'Ly�t OZG v� !T 3 dv ��9�►/�cu✓d'r2t-e AddressL �jy O z 3¢,? Assessor's Map/Parcel: 706 7 _�j4 Z Engineer's NEW CONSTRUCTION REPAIR Telephone# 51 Land Use Slopes(%) ��o Surface Stones Distances from: Open Water Body N�4 /�� W P y ft Possible Wet Area ft Drinking Water Well ft DraT by y vp ft Property Line Z U ft Other ft W —TZc`� G�33e✓ tv✓ vw SKETCH:(Street(Street name,dimensions f lot,enact locations of test holes perc tests,locate wetlands in proximity to holes) r '— L- ba OP. i m '--� n v . 304tiC_ I Parent material(geologic) Gtd (a,J S WGanJ e✓ // Depth to Bedrock Depth to Groundwater. Standing Water in Hole: a Weeping from Pit Face '� °'✓G' \ Estimated Seasonal High Groundwater �! DETERMINATION FOR SEASONAL HIGH WATER TABLE Method-Used: th Observed Stan ' g in obs. le: in. Depth tt) ttics;_ , Dept o weeping m side of obs.ho �L"'l Index Well# in, ©roan Ater AdJus Re ing Date: Index Well level Aqj,fae or Adj,Oro dm PER TEST Daft;!° �, l� Th„�� F# 1 / ��i/ / Time at 4" - Depth of Perc '4 Z o he f��y Time at 6" Start Pre-soak Time @ Time(9"-6") ,— Sm' 11 End Pre-soak re Rate Min./Inch - 1 Site Suitability Assessment: Site Passed Site Failed:. Additional Testing Needed(Y/N) .Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable"Conservation Division at least one (1)week prior to beginning. Q:\SEPTICIPER CFORM.DOC IL - DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,%Gravel) ,S-Z •v DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) /o�6f431 ✓yp v7 2 e Coun 014C DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Con i to c %Grave DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Tex,ure Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Gravel) F:,od Insurance Rate Man: / Above 500 year flood boundary No— Yes Withi n 500 year boundary No Yes WitlJv 100 year flood boundary No, Yes ;..� Depth of Natttrally Occurring Pervious Material Does at least four feat of naturally occurring pervio s material exist in all areas observed throughout the area proposed:for ti;e soil absorption system'? 5 If not,what is the depth of naturally occurring pervious material? Certificatio}.i I certify that on ri (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise andxeri A e described,in 310 CMR 15.017. Signature_ '`� A Ahj Date c Q:\$EPTiCU"ERCFORM.DOC HYANNIS BED. LIV. DIN. 1 „ ° Ln —� BREEZ. J ok 2 BED.- BATH BED. KIT. I � } LOCUS "pp � t ISA N w � LEN E STREET < ISAST. o= HOUSE LAYOUT Z 36.2 V) X- — — ETW_ 35• C.BASIN SMITH ST. - - - - - - - - -_ _ 35.9 CRAIG ROA EACH D S86'51)50)$Ell I 112.27' W I I x5.9 LOCUS MAP I J ¢�� \2 \ LOCUS INFORMATION 0- `\ PLAN REF: 139/11 F-1 h I Q o I LA TITLE REF: 3310/210 A§O• W I 135•7 PARCEL ID: MAP 267 PAR. 042 NOT IN STATE ZONE II I 1 p ZONE: "RB" AQUA. PROT. (AP) o I PARCEL ID: I FLOOD ZONE: "C" i 267/042 1 I COMMUNITY PANEL: .;250001-0008-D DATED:07/02/92 AREA=13,616t S.F. 1 SEPTIC SYSTEM PARCEL ID: ! #98 �i � A o i o REPAIR PLAN 267/043 DWELLING � �~ � GP�Qo�� �o N I O LOCATED AT: T I r #98 I SALEN E STREET INV.=35. INV.=35.67',�,,,,; No I i = HYANNIS, MA. bo SWEEP / oP�\o �6 5 / I Z PREPARED FOR W/ . I DAVID & EVELYN N PROP. BASK-IN ~N TBM=37.00' W TA I W/S WEE P nit � / i D NOVEMBER 19, 2010 S COR. BLHD O cEss. to O °a O � 1A s.A.S. C 36.4' .BASI�I ap ti ® 1 ,z� o� o EDWARD o DAVI LA ' 35.42 o A. 32.0' J �� } 1 0 FLA " STONE o ER R�I� 7c35.8 N -28 8 FENCE N86°51'50"W �Ni7 Rya (J PUMP & REMOVE 141�71' CESSPOOLS & L.P.P. PARCEL ID: PER TITLE 5 PARCEL ID: c{ 267/046 267/153 E. A. S. SURVEY, INC. GRAPHIC SCALE 141 ROUTE 6A d I SALT POND BUILDING 20 0 10 20 40 I so P.O. BOX 1729 - 60 SANDWICH, MA. 02563 ( IN FEET }1 inch = 20 ft. BUS:(508)888-3619 CELL:(508)527-3600 _ , ' ;# SHEET 1 OF 2 J 1285 TOP OF FOUNDATION (,2). _ EL=37:67 CLEANOUT3 4" SCHEDULE 40 P.V.C. 12' W/SCREWCAPS MIN. PITCH 1/8" PER FOOT (2) OBSERVATION PORTS (10' MIN.) TO GRADE W/SCREWCAPS TO GRADE ..EL=36.5. - EL= 36.4 __ ...,......,.(................ ,...,.,.......,,.,.,...,.� .., 36. EL= 36.0 ................ .. EL 1 2 ,.,, .., EL= 36.0 '6 MAX..:......::::: :: E;: Aga.....;;;;;;;;:;;..,..,......,....,...,..,... STEEL 4 BAND " ...... :BB°..., as;;;::;:;; : »»>......... • (2) 9 MIN. .................,,� CONNECTORS COVER CONC. CLEAN SAND FILL SWEEPS RISER & PER 310 CMR 15.255 EL= 35.7 LEVEL INVERT BETWEEN AND TO A MIN. OF 6" 2.5 12' ® S=.04 6.0 S= .18 COVER FOR 2' EL= 33.17 OVER UNITS FLOW LINE "T" 5.0' i S=.01 EL= 33.5 INVERT INVERTS 110" 14" IEL= INVERT INVERT INVERT (UNDER SHOWER) EL=34.77 MIN. EL= 34.52 EL= 33.39 6" SUMP EL=33.22 8"- 12" ' EL= 32.5 EL=35.67 4 BAFFL 6" B COMPACTED MECHANICALLY INVERT 32.0' (EXIST.)E PROP. DIO 24-QUICK 4 STANDARD INFILTRATORS (2ND PIPE) 30.16 DISTRIBUTION 6" BASE OF MECHANICALLY �� 34"W X 48"L X 12"H EACH COMPACTED SAND BOX W/ T ( ) PROPOSED SOIL ABSORBTION SYSTEM (S.A.S.) (BED FORMATION) 8.5' X 32' 1 ,500 GALLON; TANK PROFILE OF '' 34" No. SEWAGE DISPOSAL SYSTEM CLEAN SAND FILLLo (NOT TO SCALE) 8„ N 8.50' GEN ER END VIEW A L NOTES I CERTIFY THAT I AM CURRENTLY APPROVED BY THEI DEPARTMENT OF BOTTOM OF TH #1 ELEv.= 24.9 ENVIRONMENTAL PROTECTION PURSUANT TO 310 CMR'; 15.017 TO CONDUCT (NO GROUND WATER) 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. SOIL EVALUATIONS AND THAT THE ABOVE ANALYSIS HAS BEEN PERFORMED TITLE 5 AND THE TOWN OF BARN;STABLE RULES AND REGULATIONS FOR SUBSURFACE DISPOSAL OF SEWERAGE. BY ME CONSISTENT WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE DESCRIBED IN 310 CMR 15.017. I FURTHER CERTIFY THAT THE RESULTS OF MY 2. AT LEAST ONE ACCESS PORT OVER TANK TEES SHALL BE DESIGN DATA: ACCESSIBLE WITHIN 6" OF FINISH GRADE, WITH ANY REMAINING SOIL EVALUATION, AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM, ACCESS PORTS BROUGHT TO WITHIN 6" OF FINISH GRADE. ARE A_CCU ATE AND IN ACC RDANCE WITH 310 CMR 115.100 THROUGH 15.107. 3 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE NUMBER OF BEDROOMS•••••••••------- KIN NLE$S THEY ARE _.-`'� ,�'t 1 -`L� GARBAGE DISPOSAL.................-- NO -- CAPABLE OF WITHSTANDING H-10 LOADING UNDER IT WITHIN 10' OF DRIVES OR PAR G AREAS THEN THEY­ MUST ;-EDWARD A. STONE, CERTIFIED SOIL EVALUATOR TOTAL ESTIMATED FLOW MUST WITHSTAND H-20 LOADING. _ 4. THE EXCAVATION CONTRACTOR, SHALL VERIFY THE LOCATION (110 GAL./BR./DAY X 3 BR.) 330-330 OF ALL UTILITIES; PRIOR TO ANY EXCAVATION. 330GPD X 200% = 660 GAL 5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE TEST PIT RESULTS: P 13095 INSTALL: USE NEW 1500 GAL. TANK OR WITHIN 6" OF GRADE SHALL BE MORTARED IN PLACE. 6. FINISH GRADE SHALL HAVE A MINIMUM; OF 2% GRADE SOIL TEST DATE: OCT. 21, 2010 24 QUICK4 STANDARD INFILTRATORS (34"W X 48"L X 12"H) OVER THE S.A.S. AND DISTRIBUTION BOX: AND BACKFILL WITH CLEAN SAND FILL PER 310 CMR 15.255 7. SEPTIC TANK SANITARY TEES SHALL BE CONSTRUCTED OF B.O.H. AGENT: DAVID W. STANTON, R.S. SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6"' ABOVE SOIL EVALUATOR: EDWARD A STONE (8.5' X 32') THE FLOW LINE AND SHALL .BE ON THE CENTERLINE AND SOIL CLASSIFICATION................__ LOCATED, DIRECTLY UNDER THE CLEANOUT MANHOLES. BACKHOE: RODNEY FISHER 8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN DESIGN PERCOLATION RATE..... <2 Iv.JlN-AN 2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT EFFLUENT LOADING RATE.........-_74 ELEVATION of THE OUTLET PIPE. REQUIRED LEACHING CAPACITY.....330- GAIDAY �� 10. THE UTLET9. THE SEPTIC TSANITARYLTEE SHALL MINIMUM COVER OF 9 EQUIPPED WITH A INCHES. DTH#1 EL.=35.9 PERC RATE<2MIN./IN. ©42"BOT• LEACHING CAPACITY ;�4�.72 GA�DAY $°1 3l BAFFLE, 4 INCHES IN DIAMETER AND CONTRUCTED OF 4" PVC. ELEV. DEPTH (IN.) HORIZON TEXTURE COLOR MOTTLING OTHER 3 ROWS OF 8 INFILTRATORS -1 11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND ( ) ( ) FIRST TWO FEET OUT OF THE DISTRIBUTION BOX SHALL 35.2 0"-8" A LOAMY SAND 10YR4/3 --- ----- 96 L.F. X 4.72 S . .F.= 453 S.F. BE LEVEL. 33.7 8"-26" B LOAMY SAND 10YR5/6 --- ----- 453 S.F. X .74 GPD./S.F.= 335 GPD 12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION ""-132 C COARSE SAND 2:5Y7 4 TO EAS SURVEY, INC. FOR B.O.H. AND DESIGN 24.9 26 / --- ------ ENGINEERS REVIEW AND APPROVAL. NO GROUNDWATER/NO MOTTLES 335 GPD PROVIDED - 330 GPD REQUIRED = 5 GPD RESERVE ��NOFM4SS Z�OF� DTH#2 EL.= 36.2 1 �`� y>`� S CONSTRUCTION NOTES: ' 0, SEPTIC SYSTEM DETAIL PAGE ID 1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND DAV s o� EDWARD �s ELEVATIONS; AND SITE CONDITIONS PRIOR TO COMMENCING. ELEV. DEPTH (IN.) HORIZON TEXTURE COLOR MOTTLING OTHER �g �� A #98 ISALENE STREET �I WORK ON THE SITE. 34.9 0"-16" A LOAMY SAND 10YR4/3 --- ----- F H STONE �' 1-A HYANNIS, MA. 2. NO,DETERMINATION HAS BEEN MADE AS TO: COMPLIANCE 34.0 16"-28" B LOAMY SAND 1OYR5/6 --- ----- N p o• 2898 p WITH DEEDED OR ZONING; REGULATIONS. OWNER / APPLICANT 40IS TO OBTAIN SUCH DETERMINATION; FROM APPROPRIATE AUTHORITY. 25.2 28"-132" C COARSE SAND 2.5Y7/4 --- ------ �O�S7EP� N.OVEMBER 19, 2010 3. AL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC MARKING NO GROUNDWATER NO MOTTLES S� ITA �Pa L LA TAPE OR A COMPARABLE MEANS. / SHEET 2 OF 2 J# 1285