HomeMy WebLinkAbout0041 KEEL WAY - Health r �p 41 Keel Way ' �
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..: .. .� . � . . .� 247 170
Hyannis_
o
Commonwealth of Massachusetts
f
Title 5 Official Inspection .Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
41 Keel Way Assessor's Map: 247 & Parcel: 170
Property Address
Madge C. Ladue
Owner Owner's Name
information is Hyannis MA 02601 September 19, 2013
required for 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:when A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector: 'L (�
key to move your I•'(I_ - U
cursor-do not Richard Judd 111TTT l VV
use the return Name of Inspector
key.
Moran Engineering Associates
Company Name
P.O. BOX 183
Company Address
reran South Harwich MA 02661
City/Town State Zip Code
508-432-2878 S19584
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 F ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
September 19, 2013
In ctor s Signature Date
The system ins 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 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.
i5ins•3/13 Title 5 Offidal Inspection Form:Su J.c.Sewage Disposal System•Page 1 of 17
' Commonwealth of Massachusetts
ME Title ,5 .'Official Ins.pe.ctio•n :Form ;
Subsurface Sewage,-Disposal System Form Not for Voluntary Assessments--
41 Keel Way Assessor's Map: 247 & Parcel: 170
Property Address A
Madge C-.Ladue
Owner. Owner's Name
information is H annis 7 MA. 02601 '.September 19, 2013
required,for every y
page. Citylrown• State Zip Code Date of Inspection
R Certification (cont.)
Inspection Summary: Check KB,C;D or E Lalways complete all of Section D ;
A) :System`Passes:
'® I have not found any information which indicates that any of the failure criteria described r
in 310 CMR 15.303 or in 310 CMR 15'304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
♦ • !' r ♦, "
i •
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.
• i •
Check the box for"yes", "no""oi�:`not determined" (Y,'N, ND)for the following statements. if"note
determined"' please explain.
x
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.
f ,
*A metal septic tank willpass 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: ,
L ❑ Y' ❑ N . ❑ ND (Explain below):
I 1
l5ins•3/13 ,' 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
41 Keel Way Assessor's Map:247 & Parcel: 170
Property Address
Madge C. Ladue
Owner Owner's Name
information is required for every Hyannis MA 02601 September 19, 2013
page. Cityrrown State Zip Code Date of Inspection
R 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 (cost.): ,
❑ 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 FIND (Explain below):
❑ obstruction is removed ❑ Y ❑ N FIND (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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
s Commonwealth of Massachusetts
Title 5- ffici 'Finspection. Form � �
o
Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments +.
41•Keel Way Assessor's Map: 2474 Parcel: 170 r
Property Address
.,,'Madge C. Ladue
Owner - Owner's Name `
information is required for every Hyannis - MA 02601 •Sep tember'19,.2013 + `
page. 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)
b determines`that the-system is functioning in.a manner that protects,the public health,
safety and environment: ;
,0 The system has a septic tank and soil,absorption system (SAS)and the SAS is within
`100 feet of a surface water supply or tributarytto a surface water supply.. '
�❑ The system ha's 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 �µ
more from.aprivate watersupply 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
El ® clogged SAS or cesspool - '- . I '
Discharge or ponding of effluent to the `surface of the ground or surface waters Y
El ® due to an overloaded or clogged SAS or cesspool
t
® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
y ❑ ® Liquid-depth,.in cesspool is less than 6" below invert or available volume is less
than 'z day flow
t5ins•3/13. 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
41 Keel Way Assessor's Map: 247 & Parcel: 170
Property Address
Madge C. Ladue
Owner Owner's Name
information is Hyannis MA 02601 September 19, 2013
required for every y P
page. CitylTown State Zip Code Date of Inspection-
B. Certification (cont.)
Yes No .
El ® 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 orprivy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary.to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system.is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts • '
Title -5• O.fficial ``:Inspection" :Form t
Subsurface Sewage:Disposal System�Form- Not for Voluntary Assessments,
41 Keel Way Assessor's Map:.247'&Parcel: 170
Property Address
Madge C..Ladue
Owner• Owner's Name F
information is Hyannis MA 3 02601 September,19,2013 r
required for every ;
page. 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?
' a •
_ ❑ ;® Have large volumes of water been introduced to the system recently or as part of c
this inspection?
Y . ® ❑ .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?
Z. ❑ Were all system components, excluding the SAS, located on site?
®` "❑ 'Were the septic tank manhole`s 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? i
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. .
r® ❑' 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 jhformation e `
Residential Flow Conditions:
` Number of bedrooms 1(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example; 110 gpd x#of bedrooms): . 330. 349,
provided.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 ,
Commonwealth of Massachusetts
Title 5 Official .Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
41 Keel Way, Assessor's Map: 247 & Parcel: 170
Property Address
Madge C. Ladue
Owner Owner's Name
information is Hyannis MA 02601 September 19, 2013
required for every Y p
page. C4rrown State - Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
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 ears usage d 2012 = 27
9 ( Y 9 (gP )) 2011 = 31
Detail:
The dwelling is occupied seasonally.
Sump pump? ❑ Yes ® .No
Last date of occupancy: CURRENT
Date
Commerciallindustrial 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.):
1 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
{
Commonwealth of Massachusetts
Title ,5 ,0fficial inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•41•Keel Way Assessor's Map:.247 &Parcel: 170':
Property Address
Madge C. Ladue
Owner Owners Name
information is required for every Hyannis MA 02601 September 19, 2013
•
page. Cityrrown State Zip Code Date of Inspection
:D. S,ystern-information (cont.) ;
Last date of occupancy/use: Date ; f
Other(describe below):
General Information
MPumping'Records: t
•
aSource of information: Barnstable Health: no record(s)on file.
r _ 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 ti ,
' . '' ❑ 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.
w' ❑ Other(describe): +
t5ins-3/13 Title 5 Official Inspection Forth: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
41 Keel Way Assessor's Map: 247 & Parcel: 170
Property Address
Madge C. Ladue
Owner Owner's Name
information is Hyannis MA 02601 September 19, 2013
required for every y p
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:
Sewage Disposal Permit 98-71 Certificate of Compliance date 12-15-98 Per BOH records.
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 37 below top of foundation:
feet
Material of construction:
® cast iron ❑ 40 PVC , _ ❑ other(explain):
Distance from private water supply well or suction line: N/A: dwelling is on town water.
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
There were no observed signs of backup or leakage, within the basement, at the time of the field
inspection.
Septic Tank(locate on site plan):
Depth below grade: top & inlet: 23". Outlet port: 12".
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1500-Gallon (H-10) _
r
i
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 by 5.7'Wide
9
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 -Offici-al InspectioW Form f
Subsurface Sewage Disposal'System Form Not for Voluntary Assessments `
41 Keel Way Assessor's Map: 247 & Parcel: 170•?
Property Address
• Madge C. Ladue •
Owner . Owner's Name
information is
required for every Hyannis MA 02601 September 19,,2013
page. , Cityrrown State Zip Code Date of Inspection
System;Information (cont.) 1
U
Septic Tank(cont.)
Distance from top of sludge to'bottom of outlet tee or baffle _
Scum thickness
Distance from top of scLzn to top of outlet tee or baffle
• 15'
Distance from bottom of scum to bottom of outlet tee or baffle ,
sludge judge, tape& probe. +x
How were dimensions determined? ;
'Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,-etc:): ' c
` r The liquid level was observed at the PVC exit line pipe invert. The PVC exit tee extends 15" below
the 48.5"flow line. The inlet side of the tank contains a side e6trance`PVC line and tee. There were
- no observed signs of backup or leakage within or above the tank at the time of the field inspection.
P.ursurant to 310 CMR 15.351 (1)*the'septic tank did not require maintenance pumping at the time of ?
the inspection.
• i.
_ I
• a 7
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete -❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
!F
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•3/13 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
41 Keel Way Assessor's Map: 247 & Parcel: 170
Property Address
Madge C. Ladue
Owner Owner's Name
information is Hyannis MA 02601 September 19, 2013
required for every y p
page. 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
15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5'�Official •Inspection] Form ,
y"
Subsurface'Sewage.Disposal System Form=- Not for Voluntary Assessments.' _' • , � • F
r 41 Keel Way Assessor's Map: 247 &,Parcel: 170
• Property Address
`-Madge C. Ladue
Owner Owner's Name
information is
required for every Hyannis i MA 02601 September 19,.2013
` page. Cityrrown State Zip Code Date of Inspection .
D.`System:Information (cont.)
`Distribution Boil:(if present must be opened)(locate on site plan): k
«" 0 Depth of liquid level above outlet invert
` Comments (note if box•is level and distribution to outlets-equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The box is a D13-3/1-1=10. Surface'to access cover: 12". The box contains one inlet line and one outlet.>
line. There were no observed signs of solid carryover, backup or leakage within or above the box at .' • _
tr -the time of:the field inspection.
• - 4.i
. i
Pump Chamber(locate on site plan):
r Pumps in working order: r ❑ Yes ❑ No*
Alarms in working order: - - ❑ Yes ❑ No*
+
r Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ;
i
" If pumps or alarms are not in working order,system is a conditional pass. Y'
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
;f
+ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pa r
l5ins•3/13 � _ r 9 P Ys a 12 of 17 9
4.
r .
. <C\, Commonwealth of Massachusetts
Title 5 Official Inspection. Form
:l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 41 Keel Way Assessor's Map: 247 & Parcel: 170
Property Address
Madge C. Ladue .
Owner Owner's Name
information is r
required for every Hyannis MA 02601 September 19, 2013
page. City town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ 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.):
SAS: 3-Infiltrator Maximizers with 4' of stone along sides and T of stone at ends. SAS size: 10.83'
Wide by 27.75'Long by 2.0' Deep. Surface to top of SAS: 32". The west side of the SAS was hand
excavated to the surface stone. The sidewall stone was probed to a depth of 62". There were no
observed signs of standing liquid within the probed observation hole. The soil conditions above the
SAS did not show any signs of backup or breakout.
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 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
'Commonwealth of Massachusetts
Y
title 5 Official 'Inspection
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4
41 Keel Way!`1 Assessor's Map: 247 & Parcel:170 ;
Property Address
Madge C. Ladue J'
Owner • Owner's Name `
information is Hyannis MA 02601 - September 19, 2013 f
required for every -
page. ' Cityrrown State Zip Code Date of Inspection
ID. System Information (cont.)
Comments (note,condition of soil,,signs of hydraulic failure, level of.ponding, condition of vegetation,
etc.): ,
a
"Privy(locate on site plan):
• `Materials of construction:
Dimensions k
Depth of solids ry
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
R
'r
• r ►
t5ins•3/13 �' 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
w 41 Keel Way Assessor's Map: 247 & Parcel: 170
Property Address
Madge C. Ladue
Owner Owner's Name
information is Hyannis -MA 02601 September 19, 2013
required for every
page. 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
( i
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-:5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
i
• . ,. - • - 1. R
•N Commonwealth of Massachusetts ,
Title 5 O:fficial Inspection Form
Subsurface Sewage Disposal SystemForm -Not for Voluntary Assessments
= 41 Keel Way Assessor's.Map:•247 & Parcel: 170
Property Address
Madge C. Ladue -
Owner Owner's Name -
information is '•t •
ya Hnnis MA 02601 September 19, 2013
required for every '
page. Cityrrown,: State Zip Code` Date of Inspection
D.`System Information'(cont.) a
•
Site'Exam: .
® Check Slope
,
® .Surface water '
® Check cellar ,
T❑ Shallow wells
>5.0 below the floor of the SAS.
Estimated depth to high ground water: feet
Please indicate all'methods used to determine the high ground water-
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date 8
Date
i . ❑ Observed site (abutting property/observation hole within 150 feet of SAS)
• Checked with local Board of Health -explain: r '
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain: .
You must describe how you established the high ground water elevation:
• Per Design Plan:
Floor elevation of the leaching area: EL. 42.05. ,
Bottom of dry(witnessed)test hole(11.0') EL. 36.05.
Bottom of dry test hole to floor of SAS:. 06.00'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
. s
i
Commonwealth of Massachusetts
_ . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Keel Way Assessor's Map: 247 & Parcel: 170
Property Address
Madge C. Ladue
Owner Owner's Name
information is His MA 02601 September 19, 2013
yann
required for every p
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
® Sketch of Sewage Disposal System either'drawn on page 15 or attached in separate file
r5ins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Assessing As-Built Cards Page 2 of'3
SeU TOWN OFBARNSTABLE '+-
• LOCATION 7 �w� G1A SEWAGE#
VILLAGE -PO r-r ASSESSOR'S MAP&PARCEL `
INSTALLERS NAME&PHONE NO.
'SEPTIC TANK CAPACITY /,COO
LEACHING FACILITY:(type (size)Sg)c I I s`
NO.OWNER
PERMIT BEDROOMS 3 _
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 within200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility,(If any wetlands a dst ,
within 300 feet of leaching fac(lity) Feet
_ FURNISHED BY IA_ Sptt,1 on
- •, - Ask 8 ,`.
3 Y 33
http://www.town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=247170&seq=1, 8/29/2013
�kV677 a�
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS P 1S-0,
DEPARTMENT OF ENVIRONMENTAL PROTECTION
S�
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 41 Keel Way
West H annisport. MA 62672
Owner's Name: Madge Ladue TT
Owner's.Address:
i
Date of Inspection: August 1. 2007 .
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: '(508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that'the information reported
below is true, accurate and complete as of the 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
Ne s Further Evaluation by the Local Approving Authority
Fa. s
Inspector's Signature: Date: August 8. 2007
The system inspector'shall subs 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.
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
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 41 Keel Way
West Hvannis ort M4
Owner: Madge Ladue
Date of Inspection: August 1. 2007
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:
i
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
• Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 41 Keel Way
West Hyannisport. AM
Owner: Madge Ladue .
Date of Inspection: August 1. 2007
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to detennine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board'of Health (and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has aseptic 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 coliforn
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
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Page 4 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 41 Keel Way
West HyanniWort. MA
Owner: Madge Ladue
Date of Inspection: August 1. 2007
D. System Failure Criteria applicable to all systems:
You must indicate either"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
✓ 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 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.]
No (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 System:
To be considered a large system the system must serve a facility with.a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 41 Keel Way
West Hyannisnort MA
Owner: Madge Ladue
Date of Inspection: August 1, 2007
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?
✓ 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 infonnation on the proper
maintenance of subsurface'sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been detennined based on:
Yes No
✓ _ Existing infonnation. 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(3)(b)J.
5
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 41 Keel Way
West Hvannisport, AM
Owner: Madge Ladue
Date of Inspection: ,4uQust 1. 2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: I or 2
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on°310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease.trap present(yes or no):
Industrial waste holding tank present(yes or-no)
Non-sanitary 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: Never pumped -per owner
Was system pumped as part of the inspection(yes or no): No
If yes,vole ne 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed on 1211 S/98-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 41 Keel Way
West Hyannisnort VA
Owner: Madge Ladue
Date of Inspection: August 1, 2007
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 21"
Material of construction: ✓ concrete _metal _fiberglass polyethylene
_other(explain)
If tank is metal list age: _ Is age confinued by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1506 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee.oi•baffle: 30"
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
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage, etc.).
Tees were present. The outlet cover was 12"below grade There did not appear to be any signs o leakage
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Connnents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
i
7
Page 8 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 41 Keel Way
West Hvannisdort kL4
Owner: Madge Ladue
Date of Inspection: August 1. 2007
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarn in working order(yes or no):
Date of last pumping:
Comments(condition of alarn and float switches, etc.):
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 level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
8
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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: 41 Keel Way
West Hvannisport MA
Owner: Madge Ladue _
Date of Inspection: August 1. 2007
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers, number:
✓ leaching galleries,number: 3-28'x I L-Per as built card
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.):
The izallevs were clean. There did not meat-to be any signs of failure. A video camera was used. or the inspection.
CESSPOOLS: None (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 or no),
Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: None (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.):
9
i
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 41 Kee!Way
West Hyannispor t 1l'IA
Owner: Madge Ladue
Date of Inspection: August 1: 2007
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
1 3a ;n
3 YR 33
10
�C
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 41 Keel Way
West Hyannisport, MA
Owner: Madge Ladue
Date of Inspection: August 1, 2007
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30+/- 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:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation: .
Using Barnstable topographic and water contours snaps the Wraps were showing approximately 30'+1-at this site
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in the future. There have been no warranties.or•guarantees, either expressed, written.or implied,
relating to the septic system, the inspection, this report and/or any components of the septic system which have not
been located and inspected.
11
Town of Barnstable
�pIHE
y ti� Regulatory Services
BAMSfABM
Thomas F. Geiler, Director
MASS.
039 Public Health Division
ArFp�r A
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-8624644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved.at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
77
TOWN OF BARNSTABLE C
LO( :T ION I ��I L4JA SEWAGE# 0
JII,LAGE H- PO r-r ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY SUO
LEACHING FACILITY:(type) G AI (size) 40)(1
NO.OF BEDROOMS 1I3
OWNER
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 Spe.r,'' lun
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4-1
3 'YR 33
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TOWN OF BARNSTABLE
--LOCATION ee L W SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT d" - I70
"'INSTALLER'S NAME&PHONE NO. IZ' (3- Out a)-oS3 n
SEPTIC TANK CAPACITY IS-0 (QC-cASA-
LEACHING FACII.TTY: (type)GAtI (size) P& ��'
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: !� S' R`S COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5 Feet
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and aching Facility(If any wetlands exist
within 300 feet o , g fac ) w Feet
Furnished by
i
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f'
TOWN O,F,.BARNSTABLE
LOCATION L QQ, 14jo S
' VILLAGE ASSESSOR'S MAP LOT::
I
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY ) O 0
LEACHING FACILITY:(type) l0 Ov (size)
NO. OF BEDROOMS PRIVATE WELL OR UBLICI WATE
BUILDER OR. DWNE a e L
DATE PERMIT ISSUED:
DATE C611PLIANCE ISSUED:
VARIANCE GRANTED• Yes _ No
,� j!/2N►SII�(, ��l J
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DEEP OBSERVATION HOLE LOGS LOCUS.
DEEP OBSERVATION HOLE /fl
DEPTH FROM SOIL SOIL SOIL COLOR SOIL
TOP OF D.O.H. 1 7 SURFACE In. HORIZON TEXTURE (MUNSELL) MOTTLING OTHER k'ESt
„` "
11 fill 5,L, I O'Y X61t. NoWsrMAIN
I,- IISyjL,S. l0 (KWl_-
„ 11 l.' 7
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BOTTOM OF PERC A T.5-1-Coal TIME: It:00 AIM
5. SAd`•iD RATE: G ZMIN./INGN DATE: Ia/(v/98 G.W.E 0 NbNE Locus
PERFORMED BY: RICHARD JUDD WITNESSED BY Z DUNNINET
TEST Zy
DEEP OBSERVATION HOLE J2
DEPTH FROM SOIL SOIL SOIL COLOR SOIL I
TOP OF D.O.H. ? TEXTURE MUNSELLA40TTLING
BREn1Uq CAK
_757 B - 1-7 8
BOTTOM OF PERC AT. TIME.
RATE: DATE: G.W,E
PERFORMED BY. RICHARD JUDD WITNESSED BY.
I 1•t '�: ' ii I {t r '
DESIGN DATA.
1. REQUIRED FLOW:_ BEDROOMS X 110 GPD/B.R. 330 GPD
2. SEPTIC TANK CAPACITY: 3_5Q_'GPD X 2 = "0 GPD
USE (1) 150C) GAL. N-10 SEPTIC TANK
I lo�l.lD
J. LEACH FACILITY DESIGN: C4b�10) IDI 1
SIDE AREA: : _..2 ( IOIa'llt 27.75')X2 X 0•74 gal.
BOTTOM AREA: 10,63'X 27,75',X 0,74 oj*&/5•f. . = CgG.f ) PRoeosep 15��u. �'"'
TOTAL = 3S&,5 8 ' Serr►c LANK
3-3 6, ro,"
6, GPD PROVIDED > 3 b GPD REQUIRED -�
RESERVE AREA 1009: LEACH CAPACITY P� 1
USE:_)).M�-TRATIOK MAX IM17_@105 .%Q/. C. SKDt5
t
ESTIMATED HIGH GROUNDWATER CALCULATION NA K
I x 6'. Eaclsr• 3 BIZ
(USGS/CCC METHOD) : .1 •i
oIc,se4B•oo T'O,FDN.F-L. 99.8I
INDEX WELL: I ZONE: P,y,. �.��• Fut`�..GEtL.AP�
DATE OF READING.--DEPTH TO GROUNDWATER:
GROUNDWATER LEVEL ADJUSTMENT: -'�'tI�C- 0 ti 7S' D . E.X rooLq 3 .
ACTUAL GROUNDWATER LEVEL ® SITE: EL-
ESTIMATED (MAX) HIGH GROUNDWATER LEVEL: EL= Y7.7 /_ S p I I '• ' J ?
l' ,
GENERAL NOTES: I lZ
1. ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN
ACCORDANCE W/TITLE 5 OF THE SANITARY CODE & ANY
APPLICABLE REGULATIONS. PLT±f�51=__KEF _TO C;E1+1._ . L98iy� �N
2. PRIOR TO BACKFILLING THE INSTALLATION, THE SANITARIAN QT (p•►7A_5 WLT_vLRE5.QEC_T
do HEALTH AGENT SHALL BE NOTIFIED FOR INSPECTION, D EXESTJNIC�-_L POdLi A►1D ���
3. ANY ALTERATIONS TO THIS DESIGN MUST BE APPROVED BY t�CQr1D..1.T1o.C __PEiSI�°�1L ._ skK.
A A. WA-1-L L•qR 6 /+41P DRIVE 4
THE SANITARIAN dt BOARD OF HEALTH, IN WRITING. w ••'Z_
4, SYSTEM IS NOT DESIGNED FOR A GARBAGE GRINDER.
5. THE INTALLER IS TO VERIFY THE LOCATION(S) OF UTILITES, `
CESSPOOL(S) AND SEWER INVERTS PRIOR TO CONSTRUCTION.
6. ALL UNSUITABLE MATERIAL WITHIN 5 FT. IN ALL DIRECTIONS BF—W-R t 0, =1=1.50.W (A55uMEV) RESERVE
FROM THE SOIL ABSORPTION SYSTEM SHALL BE REMOVED do P,1C tyAl1- 5 ET I N I�,V(, �F�NF.. '.X I�'XZ� 0�
REPLACED W/CLEAN, COARSE SAND. _OF W OoD
Z ALL FILL MATERIAL UTILIZED FOR THE SOIL ABSORPTION 1 �Lk
SYSTEM SHALL BE CLEAN, COARSE -SAND FREE FROM I f \
DELETERIOUS MATERIAL AND SHALL HAVE A PERCOLATION RATE
OF LESS THAN 2 MIN.,4N. BEFORE & AFTER PLACEMENT. -
8. EXISTING CESSPOOL(S) TO BE PUMPED AND BACK FILLED PER Fao �V '`l�N of y�c_
TITLE 5 ABANDONMENT PROCEDURES. �� �y
Z +
9. DURING INSTALLATION, THE CONTRACTOR IS RESPONSIBLE TO H OF n.,,_� „ - - ���, �•a RICHARD
PROVIDE A SAFE EXCAVATION AREA. -- - ""' ILIC� '- \ JUDD.
J.
10. GROUND COVER OVER SEPTIC SYSTEM COMPONENTS SHALL
NOT EXCEED 36". _-_ o LA�UC q 1125C
11. ALL GRAVITY SEWER PIPE SHALL BE 4" DIA. SCH 40 PVC n No 3;56C '� ��►STE
UNLESS OTHERWISE NOTED. THE MINIMUM SLOPE OF 4" DIA. Put E-K ol0 r U.1,>
SCH 40 PVC SHALL NOT BE LESS THAT 0.01 FT/FT, 4ti �o
12. WHEREVER SEPTIC LINES CROSS WATER SERVICE LINES OR C ,,
WHEN WATER SERVICE LINES COME WITHIN 10' OF THE ui'"p�G���
PROPOSED S.A.S. - PIPES SHALL BE CLASS 150 PRESSURE
PIPE do SHOULD BE PRESSURE TESTED TO ASSURE WATER
TIGHTNESS. COORDINATE WITH LOCAL WATER DEPARTMENT.
Richard Judd R.S.
T.O. FDN, NOTE — RAISE ALL COVERS TO LEACH CHAMBERS ,
WITHIN 6 OF FINISHED GRADE 775 Freemon's W0yy
EL, 4 .61 DESIGN LOADING H-20 Brewster" MA 02631
9" MIN. 9" MIN. (508) .896-9316
36" MAX 36" MAX. LEGEND. TI T
OUTLET PIPE To LE' SEf roc f L�N ,�y
H-lo Y/ frcE� w��y �fY�}���Jc, /�A. �\ •y
BE LEVEL FOR 2 FT, MIN,
000-- EXISTING CONTOURS
PROPOSED CONTOURS OWNER:
llu
WATER '
Zr1EEL:r 19�0 '
I
Ft-FG J�PjT FI LI. •.' • • • • • • • • • • • • • • • •.•_ + (i GAS
CROU IT1 S
GAS BAFFLE '• -'•_ 05 UNDER ND UnL ES RE V I SI N
�l�i}i AL. w NO STor1E yEC�u1sCE�uN R, Dl(j
DER LN KAE ,
1 EPTIC TANK ` I �j t, o �-P-87 TEST HOLE
TO BE INSTALLED ON A LEVEL STABLE MAP: PARCEL: /70
BASE 6" CRUSHED STONE REQUIRED
PROPOSED SEPTIC SYSTEM - PROFILE 131,, v.o:u ,t I DATE: 10 I SCALE.
NOT TO SCALE
DWC NO..