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HomeMy WebLinkAbout0020 KENT LANE - Health 20 Kent-Lane i Hyannis A=291 -129 I �I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s••'•� 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every Hyannis MA 02601 10-23-2014 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Darrell Stone use the return key. Name of Inspector Cape Cod Septic Inspection Q Company Name P.O. Box 1466 Company Address Harwich MA 02645 City/Town State Zip Code 508-240-2500 S14995 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: ® P ses nditio Ily Passes ❑ Fails F rther Ev tion by t ocal provi 10-27-2014 Inspe or's Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions,of use. I I t5ins-3/13 Title 5 Official Inspectio orm.Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts OF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 20 Kent Ln Property Address Elizabeth Cleary Owner Owners Name information is required for every Hyannis MA 02601 10-23-2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic tank was pumped during the inspection B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"o�the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 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 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every Hyannis MA 02601 10-23-2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): t r. e 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 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is Hyannis MA 02601 10-23-2014 required for every H y ' page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50.feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: l D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every Hyannis MA 02601 10-23-2014 page_ City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or E] ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every Hyannis MA 02601 10-23-2014 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" „or no„as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts F Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every Hyannis MA 02601 10-23-2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: 3 bedroom residential dwelling Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 137.67 gpd 9 ( Y 9 (gpd)): Detail: 2013 -21,692 gallons 2012-78,540 gallons Sump pump? ❑ Yes ® No Last date of occupancy: 9-2014 Date Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every Hyannis MA 02601 10-23-2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Discount Septic Pumping (508-240-2500) Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Weight Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every Hyannis MA 02601 10-23-2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2006 per BoH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 25"+/- 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.): Apparent good condition Septic Tank(locate on site plan): ' Depth below grade: 20"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 gallon Sludge depth: 8" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every Hyannis MA 02601 10-23-2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 1" 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 16" How were dimensions determined? Sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grade to inlet cover 11 Outlet 20" SCH 40 tees No sign of leakage Outlet pipe higher than inlet The septic tank was pumped during the inspection Recommended maintenance pumping eve 2-3 years Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•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 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every Hyannis MA 02601 10-23-2014 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ti 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every Hyannis MA 02601 10-23-2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Grade to box 41" Cover 30" OK condition 3 outlets with speed levelers Normal liquid level No scum No sign of leakage No sign of failure Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every Hyannis MA 02601 10-23-2014 page. Cityrrown 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.): 3 (500 gallon)chambers with stone (10x30x2') Grade to chamber 46" Cover 22" Bottom 78" Dry No sign of hydraulic failure 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every H annis MA 02601 10-23-2014 Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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 20 kent Ln Property Address Elizabeth Cleary Owner information is Owner's Name required for every Hyannis MA 02601 10-23-2014 page. Cityfrown 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 IZEAK o Z 0 0 of A B 0 1?- 10 2 4 - $ - 10 3 3i- Z 21- 0 4 5 t5ins-3/13 Tithe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every Hyannis MA 02601 10-23-2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >5 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: 2006 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Plan on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Elevations from design plan Bottom of SAS ELV. 93.6 Bottom of test hole ELV. 87.3 NWE Separation >5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 20 Kent Ln Property Address Elizabeth Cleary Owner Owner's Name information is required for every Hyannis MA 02601 10-23-2014 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION Iuol �r l SEWAGE VILLAGE dt I� ASSESSOR'S MAP&PARCEL Imo'S NAME&PHONE NO. SEPTIC TANK CAPACITY I sz'® LEACHING FACILITY.(type) bsfs (size) 560 NO..OF BEDROOMS OWNER , PERMIT DATE: C ' T re DATEl,P. /D-lao- 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 .I r Jf l yf f ff�I f J i f f ? f l f f ! f � �• ' ` ♦ ♦ ♦�\ h \ \ 4 \ \ \ \ \ \ \ \ ♦ h. \ ♦ ♦ \ \ \I\!\fhf\f♦J\I\J\I\ ..� \f\I\f\'\f\I\I\J\I♦J\J\I\r\f\I\f\I\f\ \ f ! \ f\I\I\f\I\f\f\f\r\ . I f J r f r r I I f f f f f J ! f f r f J r J f f J ! f f f f f f fff f r r 1 f f f f I J f f I f I r f 35 29 31 3 3 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Kent Lane, Hyannis MA 02601 Property Address Myrna Elkins Owner Owners Name information is 9 required for 84 Rollin Hitch Road, Centerville MA 02632 October 20, 2008 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. a"`: When filling out A. General Information When r forms on the computer,use 1. Inspector: J01 z only the tab key to move your Patrick M. O'Connell cursor-do not use the return Name of Inspector key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority October 20, 2008 Inspector's Signa ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. *"*"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. LOB-264kins.doc•011106 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syst /p(o af01 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 20 Kent Lane, Hyannis MA 02601 Property Address Myrna Elkins Owner Owner's Name information is g required for 84 Rollin Hitch Road, Centerville MA 02632 October 20, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ complete always 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: Tank is not in need of pumping at this time, leaching chambers have no standing water or sidewall stains. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 08-264 Elkins.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 20 Kent Lane, Hyannis MA 02601 Property Address Myrna Elkins Owner Owner's Name information is 84 Rollin Hitch Road Centerville MA 02632 October 20 2008 required for 9 , every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 08-264 Elkins.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•IPage 3 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Kent Lane, Hyannis MA 02601 Property Address Myrna Elkins Owner Owner's Name information is g required for 84 Rollin Hitch Road, Centerville MA 02632 October 20, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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. 08-264 Elkins.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y: 20 Kent Lane, Hyannis MA 02601 _ Property Address Myrna Elkins Owner Owner's Name information is g required for 84 Rollin Hitch Road, Centerville MA 02632 October 20, 2008 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 08-264 Elkins.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Kent Lane, Hyannis MA 02601 Property Address Myrna Elkins Owner Owner's Name information is g required for 84 Rollin Hitch Road Centerville MA 02632 October 20, 2008 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? ❑ ® 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)] 08.264 Elkins.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Kent Lane, Hyannis MA 02601 Property Address Myrna Elkins Owner Owner's Name information is 84 Rollin Hitch Road Centerville MA 02632 October 20 2008 required for 9 , every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 36,000 gal. _ ( Y 9 (gpd)): 49 gpd. Sump pump? ❑ Yes ® No Last date of occupancy One month prior: to inspection Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 08-264 Elkins.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Kent Lane Hyannis MA 02601 Property Address Myrna Elkins Owner Owner's Name information is g required for 84 Rollin Hitch Road, Centerville MA 02632 October 20, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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: Compliance date 10/20/06 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-264 Elkins.doc•OB106 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Kent Lane, Hyannis MA 02601 Property Address Myrna Elkins Owner Owner's Name information is g required for 84 Rollin Hitch Road Centerville MA 02632 October 20, 2008 every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' 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.): Septic Tank(locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------- ------ Dimensions: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 1 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 13" How were dimensions determined? Measured 08-264 Elkins.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 15 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 20 Kent Lane, Hyannis MA 02601 Property Address Myrna Elkins Owner Owner's Name information is g required for 84 Rollin Hitch Road, Centerville MA 02632 October 20, 2008 every 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.): Liquid level was found at bottom of outlet invert, tees are intact and clear. Tank is not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): L08-264Elkins.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Kent Lane, Hyannis MA 02601 Property Address Myrna Elkins Owner Owner's Name information is 9 required for 84 Rollin Hitch Road Centerville MA 02632 October 20, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-264 Elkins.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Kent Lane, Hyannis MA 02601 Property Address Myrna Elkins Owner Owner's Name information is 9 required for 84 Rollin Hitch Road, Centerville MA 02632 October 20, 2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: Three 500 gal drywells. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers were found empty with no sidewall stains. 08-264 Elkins.doc 08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 20 Kent Lane, Hyannis MA 02601 Property Address Myrna Elkins Owner Owner's Name information is 9 required for 84 Rollin Hitch Road, Centerville MA 02632 October 20, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 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.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 08-264 Elkins.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Kent Lane, Hyannis MA 02601 Property Address Myrna Elkins Owner Owner's Name information is 84 Rollin Hitch Road, Centerville MA 02632 October 20, 2008 required for g — every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. II \ \ , \'\'\ . . / r r'/`r r r r • r r J r r r J / / r r / r J r J J / r r / r / / / / / /% J / / r / / / r / r r r r J r r r r r r / r / / / J / ♦ / r / / r / / / r / / / / r J r r J J / J / • / / / / / / J % /%/ 35 W 29 31 3 3 ON r 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Kent Lane, Hyannis MA 02601 Property Address Myrna Elkins Owner Owners Name information is required for 84 Rolling Hitch Road, Centerville MA 02632 October 20, 2008 _ every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20 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: 8/11/06 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Perc test performed on 7/31/06 found no water at 123". 08-264 Elkins.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 TOWN OF BARNSTABLE LOCATION T ' l oAfii SEWAGE # 2 D06 yS'J VILLAGE t rl�!/� ASSESSOR'S MAP &LOT .2 91 INSTALLER'S NAME&PHONE NO. ,S dS' S'Zo-4738 �Bf���Q� yrof SEPTIC TANK CAPACITY 1-f LEACHING FACILITY: (type) 3 S'DO�l�li� �i i�S" (size) /D X.30 NO. OF BEDROOMS 3 BUILDER OR OWNER /V5 f� PERMIT DATE: COMPLIANCE DATE: 4 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 leachi g fac ty) Feet Furnished by r L /�(� ,Yvj No. 2 u 6 b r q5-1 .. N Fee (f6 THE COMMONWEALTH OF MASSACHUSETTS ,l Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIPPricatiou for Migpogaf *pgtem Construction Permit Application for a Permit to Construct(-Repair(r:-�pgrade( )Abandon( ) vComplete System El Individual Components Location Address or Lot No.,2� A-041r �!¢H�f Owner's Name,Address and Tel.No. Assessor's Map/Parcel , 9/- !2 c4 leal / - Installer's Name,Address,and Tel.No. ,SOY-290—995 Design�'s Nam ,Address and Tel.No. 5we— S— Jns eofBuilding: a•Y /y Dwelling No.of Bedrooms_ ` L Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 gallons per day. Calculated daily flow 330 gallons. Plan Date ? 1 t d� Number of sheets Revision Date Title Size of Septic Tank 45262 Type of S.A.S. & f OX-) Description of Soil Nature of Repairs or Alterations(Answer when applicable) S-00 6;0 T/ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until.a Certifi- cate of Compliance has been issued by this Board pf Health. Signed Date _ �� Application Approved by Date — 4ollklU4. Application Disapproved for Re following reasons Permit No. 2 UO 6 S / Date Issued 6 X1 -----------_-------_ --�--- No. 6 b +si °- f �1` tl --��.. Fee o6 r !; ! THE COMMONWEALTH OF MASSACH�1, T—.T E; Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF-BARNSTABLE, MASSACHUSETTS f 0[ppYication for OigoM *pztem Construction Vermit .� Application-for a_Permit to Construct(ljrRepair( Upgrade( )Abandon( ) L`/Complete System ❑Individual Components Location Address or Lot No. 0 k�,cIr Z000eo Owner's Name,Addr ss apd Tel.No. Assessor's Map/Parcel gel 6 /w #i>'C /2� Installer's Name,Address,and Tel.No. sOg_��'7 S� Design 's Name Address and Tel.No. S yLS� ✓o,5 t/oy LIP TW o 5W1 ro vA-ic 1rq 1 �aexa/rp/q rs Type of Building: � e JfSl"r/ • it "'C'. re G C C/� y�M P � � �` 6!I ��'SN a j Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 3 U x- gallons. Plan Date d4 Number of sheets Revision Date Title i A Size of Septic Tank /�� Type of S.A.S. S tiv-.7 x� Description of Soil 1\F ' c Nature of Repairs or Altera ions(Answer when applicable) �/>Jl�� LSD© p 3 -Sda r' Date last inspected: 5 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this,,Board of Health. i Signed Date Application Approved by w'' 2 Date 101106. Application Disapproved for t e following reasons Permit No. .)U0 6 S Date Issued a ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS 3 .6e a6m S Certificate of Compliance ' THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( G.)-Repaired ( `')-Upgraded( ) Abandoned( )by �oSc Gi de �5ve'ro_s at 24 EMT'L-�ssi= f>< IA�/1i5 has been construct d id accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Od VP dated �° U6 Installer' �03 G411 i9�-- Designer>4o/Co rvl C6r1Se! 7,ver The issuance of this ermit s 11 ,of be construed as a uarantee that the s ste will un 'o a esi ed. Date p � g Inspector y g _ No. �U� U "ISI---------------------------Fee—/Gd-- THE COMMONWEALTH OF MASSACHUSETTS 4 PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Miquar *Vztem Construction Vermit Permission is hereby granted to Construct( 4-)-Repair( "Upgrade( )Abandon( ) System located at 24 A-r-ar 60,7r f'�hr�fl�1%S and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construc ton ust be completed within three years of the date of thi` pe 11 Date:_ y �� - Approved - / Oct 23 06 07: 14a Tadco Consultants 5083856003 P. 1 10/zUfAMb W:42 5984204295 JOEY'S SEPTIC PAGE 81 Town of Barnstable Regulatory Services t WL Thomas F.GeRer,Director mumi Publlc Health Division Thomas McKean;Direetor 200 Mak Strom,Hyannis,MA 02601 Oftloe:.MB-862-4644 Fan: S08 790.6304 Installer&DO_V_sr Gtrfifljog Form Date: Sewage Permit# goo(,--Vr1 Asscasoi•'s lvYal►l1?arcel _ '9 .. .. Designer: G�/i'!4fA C�JV rl[i/r_ Installer: ,�•a.,,�vt���,��,s Address:,. -mil. �na4V UAt--1. Address: On• - OG_ �" was!=ai a penWt to install a 1Q (�_ (installer)r�► ,Qs septic system at 210 - 4 AOAA-S based on a design drawn by (address) laytWOL dated (designer) �.I car*That the septic system referenced above was installed substantially.accordiog to the des*which may includc•mmi or approved ebatges.such as latual relocation of the distribution box and/or septic ftL St:ipout (if•required) was inspected-and the soils were found satisfactory. I certify that the septic system refer,wed above was installed with major changes (i.e. greater than 10 lateral relocation of the SAS or any vertical relocation of any component of the septic system)but ia.accordence with State&Loaal xtegulat6w. Pfau rev sia:u or celrti8ed wbuilt by designer to follow. Stripout(if required)was inspec164.6d the soils were Sound satisfactory. '. or ( er$signature) V.,S j c A!G :-:E i XA "O'k- A-/-71. i s ignature} (Affix np EUM RMW TO BARMUM PD LIC HEALTH DNMON. CMTMCATE Q T BE ss OTH 200 T CARD CE AB BT Q:1SeptialUesigmar CrltiEioatloat Fb�m Rev t13-09-06.dac tO 'CATION SEWAGE PERMIT NO. �0 ,�I VILLAGE INS TA LLER'S NAME i ADDRESS Ali BUILDER OR OWNER DATE PERMIT I S S U E D 'X7/� �� DAT E COMPLIANCE ISSUED C>Y' i 1 17 No.._81- Fis.....$... .D.0...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ........................ .o�-......OF......Barnstable....... --------------------------------------------•-•- Appliratiou for Uiipaiia1 Workii C outitrurtion "nutit Application is hereby made for a Permit to Construct VI) Repa' ) an Individ Sewage Disposal System at: 20 Kent Ln., Hyannis, MA_____02601 .... ..... ..............•--•- .........---••-------.._...........-••----------•----.._...-----------•...._..._................. Location•Address or Lot No. William Elkins 20 Kent L22 , Hyannis ._MA___02601 ......-•-----•-•------------------•-----------------•---------•----•••--•-.._.. ... ------- ....-- - .... Owner Address W A & B Cesspool Service 128 Bishops Terrace,_Hyannis, MA 02601-_-- a ------•---------------------•-------•-----•----.....••--••-----...--•----•--•-----------•-••••-••- Installer Address Type of Building Size Lot____-_..___________________Sq. feet U Dwelling IL No. of Bedrooms.............4..._.............__.________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. W Septic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length------------_---_ Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) PercolationTest Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-____________-----.-.__. (T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----------------_....... -------------------------------------•---•••--••------------------------•--------•..._•-••--.....--........................................................ 0 Description of Soil.........................Sand------------------------------•------------------------------------------------------------------------------------------------------- U -----...••••-------•-•------------•----•----•----------••----------------•••----••--•••-•---------•-•----------------•--•--••-•••-----•-------------•---------------••------------.....------------ ---------------------------------------------------------------------------------------------------------------------------------------------------.............. UNature of Repairs o, Alterations—Answer w en applicable. --n of -- -- 000 gallon, -cast stone packed leach pit (overflow. . . ...................•-----------------------------------------------------------------------•--••.............--•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the oard of health. Signed t 11-1��� .------....4- ---1�Sd -� �ppte ApplicationApproved By-•••--•-----------•--•-••-----------•-----------••-•-•--•----•-------•---•--------------------- Date .81--•-- Date Application Disapproved for the following reasons------------------------------------------------------------------------ ........................................ -------------------------••-•--------••----------------•----------•----...---•--•••---.....•-•---•--•-•-----•-•-------------------------••-•-•-----•-••-..._..------ -----------------............. Date PermitNo......81-............................................ Issued............4/--1 &1----------•-•------------ Da e —i i No... 1.'./..�.j F.Hic .$....5-00....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................_. Tow1.n........OF......Barnstable........ -----------•---............................... ,� lirtt#iaan fur i ru �a� Works Tonstrnrtinn rami# Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: 20 Kent Ln.R_Hyannis! MA 02b01 - ....................................................... ............•---•-•-------•...............--------•----••-•-...._.....-•-...----•.........._--•--- Location-Address or Lot No. William. Elkins 20' ,Cent Ln.,,_Hyannis,•-MA 02601 ...---..._._...---•---•-...--------•-•-----..... ....................... ---------...----•------- O & Address W A & B Cesspool Service 128 Bishops Terrace!__Hyannist_ MA 02601 Installer Address d feet Type of Building Size Lot..........................S q. Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other— e of Building No. of persons............. ............ Showers — Cafeteria 111 YP g P ( ) ( ) P.' Other fixtures .......................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Ix Septic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage=Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .........----------..................................................................................................................................... ODescription of Soil----------------------•-S •--•-••-••••••....................................................................................................................... x U .....--•••••-••--•---••-•••••-•••••••----••-••••--•-•--............................................................................................................................................. W --------------------- x installation of a 1,000 gallon, pre-cast V Nature of Repairs or Alterations'--Answer w en applicable.......................:....................................................................... fl stone packed leach pit= (over . .,4 -------------------------------•------------------------------------------------------------------------------------------------- •-•--••••••••••-••••••••--•-•••••• ................................ Agreement: r The undersigned agrees to install the aforedescribed Individual Sewag f'1 e Disposal System in accordance with /'1 �-• the provisions of l,.T t L_ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed_k& tt (�, /�-1�x !.o�ICJ f 4 1 81 �. •••------••1•-.1 ..... 4 Ate1/81 Application Approved BY 7 Date Application Disapproved for the following' reasons-------------------------•-------------------------------------.......---------------------------------......---- ----------------------------•----•-------------------•-------•---•--...._...........----------------......--------•------•-------------------------------------------...-------•-----•---•--•-•••--•••--- x°,:µ. Date ;r Permit No......5,1--............... ... .............................. Issued:_.... ... 1 82 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '4r , Town Barnstable ;:.............:•:.........:........,s..O F..................................................................................... fier ifiratr of Tuntptianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructedd (( ) or Repaired ( x) by A & B Cesspool Service, 128 Bishops Terrace, Hyannis, MA 02601 --•--------------------•----•---------••-•------------•------•-----•--•------------ 20 Kent Ln., li is MA 02601 WA1Tfam K Elkins at ----• ......... Y Tin. t ..... ............ -• •--. ..-••..... ••--••••-• -•---••••------ has been installed in accordance with the provisions of TIm 5 of The State Sanitary�Cpc�e described in the application for Disposal Works Gonsu:uction Permit No. ........ ....14_7.............. dated-.-..----_-...-.--___------.-_.-__------_----_. THE ISSUANCE OF THIS CERTIFICATE SHAL T BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � J, DATE...........4/ 1/81 "" t,rIns Pr ............ :+�-fit_ ...: ,_..,._ (.L�f i✓� s � r k�• �z v >-e.•'�� � ;�. .s k t� ^�J. y 1 .. ` �`+Y"�w vlz_� x,�' ear, a py"� 'rvvrn THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 81 .......Town..............OF...............Barnstable........................................... $ 5.00 No.... FEE........................ �i���a��1 nrk� �nn��rnr#ilan rrnti� Permission is hereby granted........A & B Cesspool Service, 128 shops Terrace, Hyannis. . . 02601 -- -•--------........ ---------------• •••..._..... --------•-• •••.......•••••• • •••...........• ...... to Constr o Rea an Individual ewa osal s em (�� ll SS D at No........ Ke21.. �Ln.P y is, �Z6 — i1 dam Akins --•-------•-------------.................•------ ......---- ---•-•-----•......-•••••--•--•......---•••......---•-• ............................ Street as shown on the application for Disposal Works Construction P it N .___..81 ._...... Dated.......................................... 4/.1/81 f d o'ard�o�IIe'a��-;,•--•----•-------...-•-•----...._ DATE................. •-----•--------.............................................. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS BENCHMARK SOIL TEST '3P OF F-DIUNDA701N 20 FT. MINIMUM FROM CELLAR DATE OF SOIL TEST MINIMUM FROM ELEV. 100-00 IC FT. MINIMUM 0 FT, SLAB OR CRAWL SPACE Fj CLEAN SAND SOIL TEST DONE BY __r (ASSUMED) CONCRETE WITNESSED BY ------Z.Q 2 _J E e_J6 I COVERS 7LOAM AN Z� SEED OBSERVATION HOLE__ 4" SCHEDULE 40 PVC PIPE E LE V. MIN. PITCH 11/8" PER FT, 2" LAYER OF PERCOLATION RATE MIN./INCH AT INCHES 7 'Wt'SHE"' STONE 7URE 6 DEPTH HORIZ TEX COLOR _�YIOTT OTHER 6" MAX. . 4' CAST IRON PIPE 6" MAX, NOT REQUIRED lLL (OR EQUAL) MINIMUM 22� -_ �9 y IsAurt' I_yi_c7l�_ PITCH 1/4" PER FT. MIN PITCH MAX M'4 X I FLOW LINE r 1 o" ELEV. -TMIN, ( ` ELEV. ED ED 0 0 0 CD ED c C11 CD 0 LEVEL 00 S ., i 0 ENCOUNTERED AT iMp NO WATER ELEV. GAS 1 ELEV. ELEV. 0 0 ED c CD 0 ED 1:3 ED c 177 0 0 �I-° o 2' o ELEV.BAFFLE 0DISTRIBUTION 00 0 0ELEV.OUTLET , " iLIQUID BOX 0 0 0 DEPTH TEE 1? 4 4s 4 FEET 14 INCHES (TO BE PLACED ON FIRM BASE; TO BE WATER TESTED I I L)ye- A L�� 500 GALLON DRKWELLS WITH 5 TONE- L-s 5 FEET 19 INCHES IF MORE THAN ONE OUTLET lob 6 FEET 24 INCHES 1500 GALLON IN AN 4 x:�L_j TRENCH' roRwrioN WELL 7 FEET 29 INCH (TO BE PLACED ON FIRM BASE) ZONE 18 FEET 34 INCHES SEPTIC TANK INDEX 31 e�, 7. 3/4" TO 1 1/2- CLEAN SOIL ABSORPTION ro;,j.- DESIGN CALCULATIONS DOUBLE WASHED STONE A�-' ADJUST NUMBER OF BEDROOMS FREE OF FINES SILT SYSTEM (SAS -r- _'� 7- GARBAGE DISPOSAL UNIT T USGS PROBABLE WATER TAB-!ELEV. = TOTAL ESTIMATED FLOW SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATER TABLE ELEV. = 110 GAL/8R./bAY X NOT TrC SCALE BOTTOM OF TEST HOLE ELEV. - ------ IJ REQUIRED SEPTIC TANK CAPACITY GAL. ACTUAL SIZE OF SEPTIC TANK GAL, SOIL CLASSIFICATION DESIGN PERCOLATION RATE MIN./IN. EFFLUENT LOADING RATE GAL./DAY/S.F. L 0.74 LEACHING AREA SO, FT. LEACHING CAPACITY (AREA X RATE) GAL. DAY I()C :;, ,Y_-Z- 4— j-4, RESERVE LEACHING CAPACITY GAL./DAY NOTES: ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 -po 12 G-n cu L:+ AND THE TOWN RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 6" OF FINISHED GRADE. 1 ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF 110.00' WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDEP OR WITHIN 10 FT. OF DRIVES OP PARKING AREAS H-20 LOADING SHALL BE 98.3 USED UNDER OR WITHINDQVFc; nc r4Q0"N_1 LOT 9 A AN",( MASONP- !IN .12, 100.0 _t S.F. 97.4 5. NO r)FTFRMINATIC)N HA$ 9FFN MADE AS TO COMPLIANCE WITH r)FFDFn jv0%x TE 40"W, 6. U71LInS SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTWAC'To(w IS TO CALL "DIG-SAFE" AT 1-888-344-?231 AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE. 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS 99.3 SITE CONDITIONS PRK)F TO COMMENCING WORK ON SITE, ANY VARIATION IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER IMMEDIATELY 8, PARCEL 15 IN FLOOD ZONE LLI 98. 9 LOT IS SHOWN ON ASSESSORS MAP -211--- AS PARCEL _jAv__ 3 TAN 0, 1 4 T 98.4 APPROVED: BOAPD OF HEAL- IH 99- 99.2 98.6 _ ATE AGE rN T Z 81,T-DRI VE 99. PROPOSED SEPTIC DESIGN 98.9 FOR Z ELKINS 110. n_ 28 9 PROJ 20 KENT LN. , LOT 9 BARNSrFA_B1,_E7, MA�E3S-i W\ 96.6 INOT FOR ZONiNG" i' PLANNING USE TADCO ENVIRONMENTAL CONSULTANTS 26 COMPASS LANE, DENNIS, MA 02638 (508) 385-2425 LEGEND: DATE SCALE 2 0' 1 EXISTING CONTOUR EXISTING SPOT ELEVATION %0.0 ----00 FINAL SPOT ELEVATION FOOT I L O�cus ?0 FINAL CONTOUR Tp SOIL LOCATION REVISED 'OE N UTILITY POLE TOWN WATER CATCH BASIN M A P REVISED SHEET 1 OF 1 GAS LINE C LOATION CESSPOOL UP CLEANOUT