Loading...
HomeMy WebLinkAbout0129 LONGVIEW DRIVE - Health a -9 Lon view Drive g Hyannis - A= 252 -089 0 <41 Commonwealth of Massachusetts , - 0 :. p Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form- Not for Voluntary Assessments /Q 9 41 1 C) Property Address to Qar o 0 ,1 Owner Owner's Name information is required for eve rY 0�-10 page. Cityi fovm State Zip Code Date of Ins ction c i 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. Inspector Infor ation filling out forms h , on the computer, 7y/ l POW' / use only the tab . �1 / key to move your Name of Inspector cursor-do not /10 4 Cam. C_H use the return Company Name / key. Q ` �� Company Address City/Town State Zip Code �o�) a�d f� Telephon�ymoer J License Number ` , r 5 B. Certification certify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the sys m: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails /6 L,,g InspectoI signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer; if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection'does not address how the system will perform in the future under the same or different conditions of use. tEinsp.doc•rev.712612018 -79e 5 Of`oal Inspection Fcm,.Subsurface Sewage C:sposai System•Page 1 of 18 i. M 1 Commonwealth of Massachusetts - Title 5 Official inspection Form r r1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / l�✓ .Fa— Property Address Owner Owner's Name Q ✓` // information is 6/ /� /w required for every { Qa �i page. City/Town State Zip Code Date of Ins ection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System P sses: I have not found an information which y o indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304`exist.Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: - ❑ One or more system components as described in the"Conditional Pass'section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes', "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. Y ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.728/2018 - ice 5 otczai irspeccon Form:suosur'ace sewage Disposes System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, Idy Z� Property Address H V( r Owner Owner's Name information is h krV / D l w required for every ` O( f page. Citylfown State ZipCode v J Date of Insp ction C. Inspection Summary (cons.) Z) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewa ge e back g up 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): f ❑ 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 iskremoved ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health:-Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: , t5insp.doc-rev.7/262018 1itle 5 Offidai:rspei=cn Fo=:Suosur ace Sewage'Disposal system•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address 4?l "z Owner 4pH Owner's Name / information is C H �` // 1✓ `��� /� required for every i` p,(, page. City/Town State Zip Code Date of specti n C. Inspection Summary (coat.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'. , Method used to determine distance: **This system passes if the well water analysis; performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: t ' 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections. Yes 'No ❑ ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or pcnding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.tloc•rev.?26/2018 Title 5'official'nspechcn Fc�—.:Subsurface Sewage Disposal System•Page 6 of 18 f „ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Pro perty Address 0 Owner Owners Name information is G�h ✓�` /� D l required for every (�/ 7'c O� JpR page. CitylTown State Zip Code Date of I spec' n C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems:'(cont.) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded i or clogged SAS or.cesspool - ❑ Liquid depth in cesspool is less than 6' below invert or available volume is less / than'/�day Clow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: U L�J Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion-of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. II ' �. Any portion of a cesspool or privy is within 50 feet of a private water supply well. U Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. r The system fails. i have determined that one or more of the above failure `J 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes'; or"no,to each of the following, in addition to the ` questions in Section 0.4. Yes +No the system is within 400 feet of a surface drinking water supply ❑ 7 the system is within 200 feet of a tributary to a sunace drinking water supply —1 the system is located in a nitrogen sensitive area (Interim Wellhead Protection L' Area—IWPA)or a mapped Zone 11 of a public water supply well i$irtSp.Qoc•2v.7262018 - Tive 5 vffica inspection Fora:Suosu�ce Sewage asoosal system•Page s of 18 r Commonwealth of Massachusetts ,IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments \V�swv� /C� Zo v1 � w ao� Property Address Owner Owners Name e P / ` ,A t information is /�/�_ / 011 required for every ` le✓1 !/ _ 4t /P /(./; page. City/Town State Zip Code Date of Insp6ction C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section C.4 above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ umping 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)) Sinsp.tloc•rev.7/2612018 Tide 5 07`J'ci inspe,:on suDs�rtiace Sewage Disposai System.Page 6 of 18 I Commonwealth of Massa chusetts Title 5' Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Lv& rleti/ r Property Address CoAlvo Owner Owner's Name Q information is Cp��e�v� � /%�� orb g required for every page. City/Town atate Zip Code Date of Inspe on D. System Information .1. Residential Flow Conditions: ' �• Number of bedrooms (design): Number of bedrooms (actual): �C DESIGN flow based on 310 CMR 15.203 (for,example: 110 gpd x#of bedrooms): Description: p00 6C., /�oh 42 M L✓ wo Ot 3 Number of current residents: Does residence have a garbage grinder? k ❑ Yes No Does residence have a water treat ment unit.? ❑ Yes e No If yes, discharges to: ' t Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes Ro No Seasonaluse? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Yes No Sump pump? (Ale. Last date of occupancy: Date ' F Site 5,—cjal':,spec'o-n=crm.Sucsu`ece Sewage Disposal System•?age 7 of 18 t5insp.doc•rev.7f2612018 Commonwealth of Massachusetts P Title 5 Official ' Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address K VIE✓ Owner Owner's Name information is / required for every 711 , 6 page. City/TownState . Zip Code Date of Insp bon D. System information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: ` Design flow(based on 310 CMR 15.203): • Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.).- Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges*to: Y Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: / Was system pumped as par'of the inspection?. ❑ Yes No If yes, volume pumped: galions How was,quantity pumped determined? a Reason for pumping: t5insp.00c•rev.7/26/2018 • 7ipe 5 officla;mscecCo,n=our:Subsurface sewage Disposal System•Page 8 of 18 g Commonwealth of Massachusetts . Title 5 Official Inspection Form �"� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Owner Owners Name information is � /'/ required for every Vx page. City/Town State Zip Code Date of Inspe ton D. System Information (cant.) 4. Type of Sys Septic tank, distribution box, soil absorption system ❑ Single cesspool e ❑ 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[/A`system by system operator under contract . ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components: date installed (if known) and source of information: l a w 4e o Jet 4!of a L Were sewage odors detected when ahriving at the site? ❑ Yes L. o i 5. Building Sewer(locate on site plan): Depth below grade: feet 6 Material of construction: ❑ cast iron 0 PVC ❑ other(explain): Distance from private water supply well or suction line: feet _ Comments (on condition of joints, venting, evidence of leakage, etc.): tle 5 C,tcai j.1spactior,co. .suc�su'a.a Sewage Jisposai System•?age 9 of 18 t5insp.dcc•rev.7126/2018 f Commonwealth of Massachusetts z Title 5 Official Inspection Form Ci Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every Cleo page. City/Town State Zip Code Date of I spectio D. System Information (cost.) 6. Septic Tank (locate on site plan): Depth below grade: SO feet Material onstruction: 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: - Sludge depth.- Distance from to of sludge 3 o p g to bottom of outlet.tee or baffle � 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 — s How were dimensions deter mined? /'� - � V,C� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Lei 00C! 0n J/-/7o% . ,moo .. t5insp.doc-rev.7/26/2018 -ide 5 OtOai Inspecoen=ortn:Suesurface sewage Disposai System-Page 10 or 18 Commonwealth of Massachusetts ,^ Title 5 Official Inspection Form i' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address -ei Owner Owner's Name information is (fe-4 required for every page. City/Town State Zip Code Date of inspec on D. System Information (cost.) ` 7. Grease Trap (locate on site plan): Depth below grade: feet .E Material of construction: concrete metal .,. ': t' '�fiberglass.. ❑ polyethylene ❑ other(explain): Dimensions Scum thickness Distance from top of scum to top of outlet tee,or baffle . r Distance from bottom of,scum to bottom of,outlet tee or baffle ' Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage; etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: ` Material.of construction: - a 71 concrete 7 metal E❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions.''. Ot Capacity: gallons Al Design Flow: gallons per day tSinsP tioc-rev.7l26i20�8- ; -We 5 o fca'.nspe=on;Fo—�:Suosu'ace Sewage Disposal System•Page 1 t of 18 - r Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l ec,✓ ,O r vac. Property Address Owner Owner's Name Q information is °o � (� required for every V6 ' Z�f page. City/Town I State Zip Code Date of Insp lion D. System Information (cons.) 8. Tight or Holding Tank (cont.) " Alarm present: _ ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required)_ Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): j Depth of liquid level above outlet invert elo 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.): • ' - : :. o.�( eve - 4 ?,Je 5 oftaal-nspacton Form.Suos.,face sewage Disposal system•?age 12 of 18 t5insp.tloc-rev.71262018 Commonwealth of Massachusetts'- -. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments zt� 9 Property Address Owner Owner's Name information is `epi�`e Il AA required for every s page. CitylTown State Zip Code Date of Insp tion D. System Information'(cont.) ` 10. Pump Chamber(locate on site plan) Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber„condition of pumps and appurtenances, etc.).- * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): if SAS not located, explain why: > i 6 Type: Soo 64 AM a ❑ teaching pits number: ❑ leaching chambers number: ❑ leaching gaileries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativeialternative system Type/name of technology: ---- ---- tsinsp.doe•rev.7262018 -me 5 Ot`oai:nsoe.pion Fcm:ScDs -aea sewage oisposai System Page 13 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection Form kw Subsurface Sewage Disposal System Form -Not for Voluntary Assessments iz Property Address Owner r! P� Owner's Name information is required for every 0 G "e page. City/Town State Zip Code Date of Inspfiction D. System Information (cont.) 11. Soil Absorption System (SAS) (cost.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc_): //r/0 rZiki-e . '41V • 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t6insp.doc•rev.7/26/2018 5we 5��aai inspecjen=o,—.sucsudace sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts lv� Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntar y AssessmentsYwv i Property Address 4), Owner Owner's Name information is / required for every C H D �,pt � �6 page. City/Town State Zip Code Date of Insp ct-on D. System Information (cons.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f . t t5insp.tloc•rev'.T@62018 L:ue 5 Cfhos,;nsoe oon.orm.Scosudace sewage asoosat System.?age 15 of 18 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - t for Voluntary Assessments Property Address Owner Owner's Name information is required for every /VC page. Ctty(TownM State Zip Code Date of Ins do D. System Information (Cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or chmarks. Locate all wells within 100 feet. Locate where public water supply enters the bull Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately I i i • I L114 0 0 O S-11(9,z14, j n I � - 3 �� �/- t � � S 1, `f`-A k �3e, > , � �, �-�- L/ t6insp.doc•rev.7/26/2018 Title 5 Officz;rspectlon=em:SUDSL.`faCe Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -9 P y Not for Voluntary Assessments Z1, Property Address Owner Owners Name LL information is �V I required for every � (/ 'e _ ak&vpage. City/Town State Zip Code Date of Insp 'on D. System Information (cons.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells /J yper� Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water eievation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting propertylobservation hole within 150 feet of SAS) Ly' Checked wit i1C_ cal Board of eaith explain: V) 7 4E-�f� ❑ Checked with local excavators; installers- (attach documentation) ❑ Accessed USGS database-explain: , You must de e how you established the high ground water elevation a u64 C(,✓-ed�-� `OC �e�✓ iLL6 ' gqeel lAr Ile, fq S Ae- Before filing this Inspection Report, please see Report Completeness Checklist on next page. 5insp.doc•rev.7262018 ,-1Le 5 3taal;rsxcJon=or:Subsu`ace sewage Disposal System•Page 17 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �9w" /el 7 n _ 004 /wit.✓ orlt l/It, Property Address C Owner Owners Name /7 information is / A� v � /6 required for every L�G� page. City/Town State Zip Code Date Anecti E. Report Completeness Checklist , Complete all applicable sections of this form inclusive of: F'OA. Inspector Information: Complete all fields in this section. E�j B. Certification: Signed & Dated and 1, 2; 3, or 4 checked IV. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 44(Failure Criteria)and 6 (Checklist)completed a D_ System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 45insp.00c•rev.712W2018 - 'ue 5 o f,au nspecaon=o,-c s=surtace Sewage Disposal system•?age is of is y ' WE Town of Barnstable �. � Regulatory Services Department + HARN3CABM "`ASS Public Health Division 200 Main Street, Hyannis MA 02601 , Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,,CHO CERTIFIED MAIL 7014 1200 0001 0358 0994 May 1, 2015 Stuart Cohen 2939 Van Ness Street Washington, DC 20008 NOTICE TO*ABATE VIOLATIONS'OF 105 CMR 410.000,(STATE SANITARY CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION The property owned by you located at 129 Longview Drive Hyannis, MA was inspected on May 1, 2015 by Timothy B. O'Connell, R.S.,,,Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a rental inspection. The following violations of the*State.Sanitary Code were observed: 105 CMR 410.500- Owner's Responsibility to Maintain Structural Elements: Loose and displaced bricks on front steps. You are ordered to correct the above violations within thirty (30) days of your receipt of this notice by-repairing the front steps. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations,please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF TH JOARD OF HEALTH U McKean, R.S., CHO Director of Public Health Town of Barnstable TOWN OF BARNSTABLE LOCATION IL4 W&VL1:W ttLW , SEWAGE# lS VILLAGE ByAy lJ I S ASSESSOR'S MAP&PARCEL arj INSTALLER'S NAME&PHONE NO.C49C, t�i� SEPTIC TANK CAPACITY [5® LEACHING FACILITY: e 3 Seca We,G AP$(size) 3-3, 1 NO.OF BEDROOMS H OWNER STUAP-T C®446N PERMIT DATE: Ct- l6--kO 1 COMPLIANCE DATE: q a?j-.1®� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Af14 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) ry A Feet FURNISHED BY OA(�-w a)C E, a.[ �Q1se< �—�� Q A-1 = 44V A-z51.4' O : A-3 ; L14• o' © Q 9-�' , A S+" 3 g.2' �ie.ls 8-4 T 3 13"S= Q'�" S•S•�{6 �rt� Town of Barnstable P# � Department of Regulatory Services DARNarnaM Public Health Division Date 0,9. 200 Main Street,Hyannis MA 02601 „ ,p Date Scheduled Time M_^^ /n) `r,er�T1 Fee Pd. �V�/ 70 tp Y� Soil Suitability Assessment for Sewage isposal , a Performed BY:_ M i(,6Ni' t m to d . E 1 T G SC ` ' r� / Witnessed By:�G��` W►'�Dn (� LOCATION& GENERAL INFORMATION Location Address Owner's Name STUAP_'T 1 aci L O N GLv i E W nR4Ub HY-40A)rS Address AO3el VOW nJaSS 5-r A)L✓ .� iNe*S(-t:fN&T0b.j E.)G ;jo0Cj Assessor's Map/Parcel.• p� ©gy Engineer's Name d4 1 SrJ t-G-RP,21 S t� NEW CONSTRUCTION REPAIR AL Telephone# 5f09 - _ 9-77 Land Use 5t"512 t�ami l We ,15 Slopes g'o l -2 508-2 73-03 7 7 r Pes( ) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line 7/0 ft Other - ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Parent material(geologic) OUEUud5�1 Depth to Bedrock Depth to Groundwater. Standing Water in Hole:_ Weeping from Pit Face Estimated Seasonal High Groundwater 7 120 t.55' C 7�btc b° +b VL ucrtheA {irvie p� trts{�n11oltc�� DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: puecA 6b5eruo ltcn See Gi�WUL Depth Observed standing in obs.hole: In, Depth to soil mottles: in, Depth to weeping from side of obs.hole: - in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level _„ Adj.factor Adj.Groundwater Level, PERCOLATION TEST Date y-&-/ ' Thne j6_�1_Y m Observation Hole# l Time at 9" - G � Depth of Perc �$ - (040 ` Time at 6" J Start Pre-soak Time @ /y 4n^ - Time(9"-6") - - End Pre-soak Rate Min./Inch L 2 Site Suitability Assessment: Site Passed S Site Failed: - Additional Testing Needed(YIN) 'y Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPT10PERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# 1 t 2- Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. ons_isteney.%Gravel) 6' 1-/ ao G DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consiatengy,% DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Sol] Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. --Consisten Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes. Within 100 year flood boundary No z Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? , Ye S If not,what is the depth of naturally occurring pervious material? Certification I certify that on 9 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed-by me consistent with . the required training,expertise a d expe ' ce described in 310 CMR 15.017. Signature /amDate Q:WEPTIC%PERCFORM.DOC i r r No.- V J 2d Fee d!/i THE COMMONWEALTH OF MASSACHUSETTS Entered in co user: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es 21pplitation for Disposal *pstrm Const union 3pPrmit Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ). omplete System ❑Individual Components Location Address or Lot No. ,Act W ,fig CU." 'piZ[allr Owner's Name,Address,and Tel.No. Assessor's Map/Parcel a5 CAL' , ao _ Installer's Name,Address,and Tel.Ao. Solt-t f Designer's Name,Address,and Tel.No. d4pew ae G Ats'ag L,4,C TC_ &XK='rrj&-E JU&ZAX� 8 6 Type of Building: Dwelling No.of Bedrooms Lot Size l cN x sq.ft. Garbage Grinder( ) Other Type of Building 12 Q79(OE),j 1 JR- No.of Persons Showers( ) Cafeteria( ) Other Fixtures ??� Design Flow(min.required) K!4,D gpd Design flow provided gpd Plan Date s— 16,aD i 5—Number of sheets I Revision Date Title !..-n Lomeyt&�W au . C iTE]2 rL 9 Size of Septic Tank 1 S 6p Type of S.A.S.� 5, 00 (2r� �� )&J Description of Soil B**iarb L('26d. — C-4 442 4 Nature of Repairs or Alterations(Answer when applicable) VJUS'MJ., A`G-(O Z?) &Xk, � do b A� IC 0 3)<c0 C�t,c.ecJ Cat� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date 9 t P Application Approved by Date !' l,¢_ 2 v Application Disapproved by Date for the following reasons Permit No. � �� -Ld Date Issued — S No. _V(� a Fee oUi. THE COMMONWEALTH OF�MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es Rpplication for BispoBal 6pstent Construction Vermit Application for a Permit to Construct( ) Repair(0�, Upgrade( ) Abandon( ) [ omplete System ❑Individual Components Location Address or Lot No. (Act (I}w„�/ (mow tiitdlJ6 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 51 J S 9ao�-/4 yA m l�'N DK Installer's Name,Address,and Tel.N`o. Designer's-Name,Address,and Tel.No.SGg;-L'73 037 508-4 Y-8$�77 e_APe&9Xa6 QJX-a�e�d4SCS u.C_ �. XC. &-K*r=14&--9VjU6r zAX_. 1:53GD S $. W f+ Type of Building: ' Dwelling No.of Bedrooms Lot Size ( 1C11. sq.ft. Garbage Grinder( ) Other Type of Building [Z f "Z'j No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided t{ gpd Plan Date q — (��,'�D( Number of sheets Revision Date Title (;n 't-tw w92A) biuuE C�l�1T�Yl f Size of Septic Tank 1 ,500 Type of S.A.S. ' , 5CIO G6ku4)6j G.Ie4��$ Description of Soil M c»1 Ea 004 5'_5-APP (0_ (LQ�� Nature of Repairs or Alterations(Answer when applicable) Z�JJ:;W[ AI G*W H-A O �SC,n 6e�u,p(J $bl�TtCs TD OCAA-) -doI-E ) D 4UZC ` ) 5c Gam! ct�# d4AWA1XC w rrk ' oc ArzlyJCx- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in _ accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. A Signe Date ry—12S—RO l s, Application Approved by Date Gr _ ,F_ 2 of r Application Disapproved by Date for the following reasons Permit No. 2 J (5—, J Z 0' Date Issued--------------------------------------------------------------------------------------------------------------------------------------- S I, m THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( -) Repaired( Upgraded( ) Abandoned( )by at C U_6 has been constructed in accordance with the provisions of Title 5 and the for Disposal ystem Construction eit No. of . Zo dated ( / Installer C9GtXb6 EVtWP Q Keg Uj',� Designer 3G z #bedrooms Approved design flow q4o gpd The issuance of this permit shall not be construed as a guarantee that the system will nctias design Date Inspector No. .c1( o Fee 0,9 - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Vermit Permission is hereby granted to Construct( ) Repair( Upgra ( ) Abandon System located at U E1J miL,6i _ fn✓t✓i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Conns� ction�,ust be completed within three years of the date of this permit. T Date, f ' ( / Approved by 9/24/2015 12 :30 5082730367 tt4274 P. 001/001 Town of Barnstable Regulatory Services 4 Thomas F. Geiler,Director ? �� a Public Health Division ► Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: 5 Sewage Permit# a®15 -N-0 Assessor's Map/Parcel 89 9 Installer &Designer Certification Form Designer: S c: EnSi�erc c� , T�C Installer- Address: )0$4 UctrMarrx tky��WT Address: 53 Commerc-Cal Street �o�� wQrc�llowl, �1A 01538 ` ?1A 02(0`/ `� 50b-273•0377 On was issued a permit to install a (date) (installer) septic system at 12 q Loo 6�v l e -0 pc 1 V e, based on a design drawn by (address) S C Enc;� neeccn5 , Tnc_ dated / (designer) V I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required)Ny ected and the soils were found satisfactory. OF CJOHN�L HURCHILL R. st ler's Signa e) iL esigner s Signature (Affix De g Here) P ' ASE RETURN TO S AB PU LIC EAL DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE-RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU. gAoflice 1'ormsldesignercertirrcation form.doe Stuart.B.. Cohen 2939 Van Ness Street,N.W. it 122,6 Washington, D.C. 20008 August t 1, 2015: For the Files RE: Number of Bedrooms at 129 Longview Drive Centervill'e,Massachusetts 02632 The house at 129 Longview,Drive Centerville Massachusetts 02632 has been in my family since my parents Jack and Betty Cohen purchased it in 1985 and.the,house has always had 4 bedrooms. Now as the current owner of 1.29 Longview Drive Centerville Massachusetts 026321 sign this affidavit attesting to the fact the house has always had 4 bedrooms. 1f you should have any questions or require any additional, nformution please contact me at 202-270- 5198 Sincerely yours,. a Stt art B.'Cohela. f ti L Yr`� r € t �-\ CONINIONAVEALTH OF I ASSAC14USETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA DEPARTMENT OF ENVIRONMENTAL P ONE WINTER STREET. BOSTON. MA 02108 617-2 2- 10 � WILLIA .F.WELD � � Gov emc ` IN 19 Secretary ARGEO PAUL CELLUCCI _ r9d 'ID B.STRUHS Lt.Governor SUBSURFACE SEWAG DISPOSAL SYSTEM INSPECTION F �� Commissioner CERTIFICATI1DN Property Address: lZC1 l,lerv�y �eew ""�''tiin��°('2 5a �'J �. C6 n—.Address of Owner: Date of Inspection: "'�'1t���i1 (If different) Name of Inspector, clrekntiLu t ` CfLto`�'L I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Mailing Address: 'S -2 ZL .k-k Telephone Number: CERTIFICATION STATEMENT I ceni y 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 rnspeoio-.. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionalk Passes Need_ Further Evalu kon y the Local Approving Authont\ Fa.— y Inspector's Signature Date: 1 IO The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection.. The original should be sent.to the system owner and copies sent to the buyer, if applicable, and the approving authorir\. INSPECTION SUMMARY: Check A, B, C,.Or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated.are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revloed 04/25!97) Page 1 of to DEP on the woad wide weD hnp.Nwww magnet.state ina.us/dec Pnnted on Recyaed Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:�G OwnerG Date of Inspection: ;7// e] SYSTEM CONDITIONALLY PASSES (contin,,-d. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box.' The system will pass inspection if(with approval of the Board of Health)". Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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(si are replaces obstruction is'removed CJ 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 the public health, safer\• and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER ., WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or priv% is within 50 feet of a surface water v, i within 50 feet of a bordering vegetated wetland or a salt marsh. _ Cesspool o� pris g t 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surtace water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ��y �O ti� Owner: �- CoG,ccs - Date of Inspection: _ DJ SYSTEM FAIL` You must indicate either "Yes' or "No' as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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. . r • _. Static Dowd level in the distribution boa 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 112 day flov,. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe's:. Number of times pumped Anv portion o'the Soil Absorption System, cesspool or privy is below the high groundwater elevation An\ pomon of a cesspool or pri\v is within 100 feet of a surface water suppiv or tributary to a surface water supply. And portion of a cesspool or prey is within a Zone I of a public well. An, portion o-'a cesspool or pnw is within 50 feet of a private water supply well Am pomon o�a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water qualm analysis. If the well has been analyzed to be acceptable, arach cop\ of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: You must indicate either "Yes' or "No- as to each of the following: The foliow ing criteria appik. to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (raviaod 04/25/97) _ Fag* 3 of 10 ♦ I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ," Z,�� t/°p. . , �Y, _ (24../e,-t, 'A e Owner: Date of Ins ection: Check if the following have been done: You must indicate either "Yes"or "No" as to each of the following: . Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. K None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection. As bull: plans have been obtained and examined. Note if they are not available with N/A. The fablin. or dwelling was inspected for signs of sewage back-up. _ The s�•stem does not receive non-sanitary or industrial waste flow. _ The site v+as inspected for signs of breakout. _ All sv stem components, excluding the Soil .Absorption System, have been located on the site. �•. _ The septic tank manholes were unco.ere•-, opened. and the interior of the septic tank was inspected for condition of baffles or tees, material o' construction. cimensions, depth of liquid,.depth of sludge, depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility o\%ner )ano occupants, if dRteren: from owner were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field iif am of the failure criteria related to Part C is at issue, approximation of distance is unacceptable [15.302(3rb?? (revised 04/25/5?) Page 4 of 10 r, t i j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q 'SYSTEM INFORMATION Property Address: 4{ l LO Owner: � - G—f� e�. Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow 3U a PAA)edroom for S.A.S Number of bedrooms Number o'current residents: Ol— Garbage g,, der (yes or no!: PC) Laundry co.—ected to system (yes or no!:�5 Seasonal use ayes or no`: l - ...._ Water meter readings, if ava able (last two ;2 &u . vear usage (gpd): (Wr. Sump Pump (ves or no): Last date of occupancy COMMERCI4UINDUSTRIAL: Type of establishment Design fjm% ealions'da� Grease trap present. ryes or no' Industrial %%aste Holding Tank present. wes or no_ .'ion-sanitary %%ante discharged to the Tale 5 system: n•es or no. „_... . Alater meter readings, if availabie Las:pave o: o c::panc, OTHER: .De_cnbe _ Last date of occuDanc. GENERAL INFORMATION PUMPING RECORDS a d source of information.. System pumped as pan of inspection: tves or no,1j_0 If yes, volume pumped eallons Reason for pumping TYPE OF SYSTEM Septic tank/distri�ut,on box/soil absorption system Single cesspool Ov;It; .'V\cw CAuh�o01 Overflow cesspool Pricy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other iAPPROXIMATE AGE of all components, date installed(if known) and source of information: aVsC�� L Sewage odors detected when arriving at the site, ryes or no) (revised 04/25/97) page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 'PART C / J SYSTEM INFORMATION (continued) Property Address: .may- f L.©�� �r e n t P�!� 11 e - Date of nT spection: 7 BUILDING SEWER: VU (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction li-t Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:00 (locate on site plan Depth below grade Material of construction: _concre:e _meta' _Fiberglas, _Polvethvlene _other(explain! If tank is metal, hs: age _ Is age confirmed b� Cert.ficxe of Compliance _(Yes"No Dimensions Sludge depth Dtsfance from top of sludge to bottom of outie: tee or ba.' e Scum thickness: Distance from top of scum to top of outlet tee or baii')e Distance from bottom of scum to bo-o-n of outlet tee or ba*f.e How dimensions were determined Comments trecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP:, Ad (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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 01!25:9,) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART C SYSTEM.INFORMATION (continued) Propert` Address: f.Z al Lo µS Owner: —X - CMG, e c� Date of inspection: TIGHT OR HOLDING TANK: Tank must be pumped prior to, or at time, of inspection) (locate on site plan; Depth below grade: Maternal of construction." concrete' metal .Fiberglass _Polyethylene _other(explain) Dimensions: Capacm: galions Design floes. gallons%da, Alarm level Alarm in working order _ Yes; _ No Date of previous pumping - Comments. (condition of inlet tee. condition of alarm and float switches, etc.) ' DISTRIBUTION BOX:- _. locate on site pan Depth of liquid level above outie: in\e Comments: (note if level and distribution is equal. evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:-4jD (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.) (revised 04/25/97) page 7 of 10 - 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: � .� (�k (/i o_e_¢� ^ (_¢' ,GC °2. Owner: e �Lz Q H Date of Inspection: . q SOIL ABSORPTION SYSTEM (SA ):_*S (locate on site plan, if possible, exca,.ation not required, bit may be approximated by non-intrusive•methods) If not determined to be present, explain: Type: ._ leaching pits, number. leaching chambers, number._ --. leaching galleries, number: - -- leaching trenches, number,length: leaching fields, number, dimensions. overflow cesspool, number Alternative s\,stem Name or Technoiogv. Comments: (note condition of soil, signs of hydraulic failur , level of pon g, co ti f vegetation etc.) Q CESSPOOLS: (locate on site an. Number and co.n.figura;ion Depth-top of liquid to inlet Inver, C,'f Depth of solids layer:_(i Depth of scum layer. e> Dimensions of cesspoo!: 4K It— Materials of construction tlar }c- Indication of groundwate- IJc7 inflow (cesspool must be pumped as pan of inspection) �.1© Comments: (n to condition of soil signs of hydraulic failure, level of ponding, ppclitio� of etation, etc.) , �T �% tI RJC MO�Y'Str-rLk 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.). (ravaaod 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) / Property Address: �� L© �S•;, U �-�_�_ r. .cam t-G�l(.^C `lam.. Owner;• L' Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all.wells within 100' (Locate where public water supply comes into house) U.C1_ 2 1 _ r (revised 04!25!97) Page 9 of 10 " j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) // ' PropertN Address: .2 Gf C_O..S V,'¢c_�_..,�r , w V �. Owner: Date of Inspection: i Depth to Groundwater w Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check %%ith local Board o! health Checi, FEkAA maps Check pumping records Check local excavators. installers `A Use L SCS Data Describe in \our own „oras n.o\% %ou established the Hieh Groundwater Elevation. (Must be completed: U 5, coo tcc� z C`Lt®kc c%C.i.�ifir�o�vg �{, A , (Oct a 51.E y 1 lzsv.s.d 0�;25!5?, Page 10 of 10 TOP OF FOUNDATION = 70.0'± FINISH GRADE OVER D-BOX= 69.6''+' FINISH GRADE OVER CHAMBERS= 70.0' - 69.7' PROP.VENT WITH CHARCOAL FILTER TO ABOVE GRADE GENERAL NOTES PROVIDE EXTENSION RISER SLOPE @ 2%MIN. OVER SYSTEM 3/4"TO 1-1/2"DOUBLE WASHED WITH COVER OVER INLET& REMOVABLE WATER-TIGHT COVER OVER STONE TO CROWN OF PIPE 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISHED GRADE OUTLET TO WITHIN 6"OF F.G. RISER TO WITHIN 6"OF FINISHED GRADE 4"SCHEDULE 40 PVC INSPECTION PORT WITH ACCESS n " n METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL @ FOUNDATION = 69.5'± F.G. OVER TANK EL.= 69.7 +' 5" DIA. OUTLET(S) MIN SLOPE 1% BOX TO F.G. (SEE NOTE 19) 2 OF 1/8 TO 1/2 DOUBLE WASHED CODE AND ANY APPLICABLE LOCAL RULES. STONE OR GEOTEXTILE FILTER FABRIC - 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE 20"MIN.ACCESS - __ - _ __._ COVER(3 TYP.) 4.53'MAX. , PLACE RISERS ON ALL DESIGN ENGINEER. PROP. SCH.40 SEE NOTE 20 5.3'MAX. � TOP OF SAS=64.00 CHAMBERS WITH „ PVC SEWER PROP. SCH.40 SEE NOTE 20 , 6.0 MAX. x 3. 4 SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL f6' 1 PVC SEWER SEE NOTE 20 BREAKOUT EL= 63.50' INLET PIPES TO 6 OF SYSTEM UNLESS OTHERWISE NOTED. FINISHED GRADE „ 2"DROP MIN. _ 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN MIN.SLOPE Q 1% .� x n ._ 3" DROP MAX. 3 9 t PROVIDE WATERTIGHT _ MIN.SLOPEQ 7%� ELEVATION =63.50' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A 4" PVC IN FROM JOINTS TYP. o 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF 14" 63.50' SEPTIC TANK 4" PVC OUT TO � � � O o o O o THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. O LEACHING FACILITY o c� 00 � � � � � 0 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. 63.75' 12" 6" �" 0 48" OUTLET TEE 63.35' MIN. 63.18' 2' oo � � � � o 0 0 o0 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. 00 00 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK 6"CRUSHED STONE °° o00 oo FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS AS BAFFLE OVER MECHANICALLY o0 0 0 o NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH 19.7'TO FND. COMPACTED BASE - 8.5' TYP _ 4 0' 5 OUTLET DISTRIBUTION BOX ( ) 40 40 AND DESIGN ENGINEER. . � 4.83' . � 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM. BENCHMARK ELEVATION OF 70.00' 6"CRUSHED STONE TO BE INSTALLED ON A LEVEL STABLE 33.5' (NP.) ESTABLISHED ON THE FRONT, LEFT CORNER OF THE CONC. WALL,AS SHOWN ON PLAN. OVER MECHANICALLY BASE. FIRST TWO FEET OF OUTLET GROUND WATER ELEV.= < 56.00' ** COMPACTED BASE PIPES TO BE LAID LEVEL. 61 .00 12.83' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION * APPROX. EL. ONLY, PROPOSED 1 ,500 GALLON H-20 CONCRETE SEPTIC TANK 3 - 500 GALLON H-20 CHAMBERS 5'MIN. CHAMBER END VIEW THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT CONTRACTOR TO VERIFY LENGTH 10'-8'� WIDTH 5'-8" DEPTH 6'-2" (Dimensions per Wiggin CROSS SECTION VIEW 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES ELEVATION & NOTIFY Precast Corp., Pocasset,MA) H-20 D I STP I B UTI ON BOA. DETAIL TYPICAL CHAMBER PROFILE **TO BE VERIFIED AT TIME OF INSTALLATION TO THE DESIGN ENGINEER. - SEPTIC TANK PROFILE H-20 CHAMBER DETAILS WEQUAQUET LAKE EL. =34.8'±N.G.V.D.ENI! 1=ER IF DIFFERENT NOT TO SCALE NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT. �- 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM TEST PIT DATA SWING-TIES , APPROPRIATE AUTHORITY. PERC NO. 14807 DESCRIPTION HC-1 HC-2 INSPECTOR: David W.Stanton, RS 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS � LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE TANK INLET COVER(1) 50.8' 25.2' EVALUATOR: Michael Pimentel, EIT, CSE THEY SHALL WITHSTAND H-20 LOADING. TANK OUTLET COVER(2) 43.9' 29.3' C.S.E.APPROVAL DATE: Oct. 1999 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. • 00 DATE: September 8, 2015 CORNER OF STONE(3) 39.9' 30.2' 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE • �, • • . TEST PIT#: 1 MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. CORNER OF STONE(4) 20.0' 59.1' f r * ELEV TOP= 69.80' REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, CORNER OF STONE(5) 32.9' 64.8' MAP 251 �' la , ' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). ` <59.80' 70x1' ELEV WATER= 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN LOT 90 �0��� . CORNER OF STONE(6) 47.7' 40.1' 70 I m uller I PERC RATE - <2 min./inch SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. * E 16. PROPOSED PROJECT IS LOCATED WITHIN: � � r � DEPTH OF PERC = 48"-66" o - Z • .' Nv 2 ASSESSOR'S MAP 251 LOT 89 TEXTURAL CLASS: 1 a, 0 69x9 a OWNER OF RECORD: STUART B. COHEN ° ---- 0 18" OAK S7 a 4 • • Cl) o - �Q1 7 16, /0"E �18-92' J ,� r ; 0" 69 80' ADDRESS: 2039 VAN NESS STREET NW APT#1226 �� e ♦ WASHINGTON DC, MA 20008 ROPOSED 3-500 GALLON I� a # • II I FEMA FLOOD ZONE X 69x6' H-20 LEACHING CHAMBERS i s ! COMMUNITY PANEL# 25001CO562J PROPOSED 4" PVC VENT PIPE- 154' WITH AGGREGATE r r Fill � r • � ' : � • 17. DEED REFERENCE: L.C.0#205582 r 6" OAK EXACT LOCATION PER OWNE� 6" OAK12 8 _ # * . r • 18. PLAN REFERENCE: L.C. PLAN#28749-B 69xT 4) 48" 65.80' 19. A 4"PERFORATED SCH. 40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A 28 HC-1 • ' • ; Perc DEPTH OF THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3"OF FINISH GRADE. A 20.0' ' r ' I 66" 64.30' REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS. APPROX. LOCATION OF EXISTING • 4i�t I CESSPOOL TO BE PUMPED AND 16 OAK �` �w� 1f . �. • * 20. IN ACCORDANCE WITH 310 CMR 15.401 -15.405,THE FOLLOWING LOCAL UPGRADE REMOVED PER TITLE 5, (TYP OF 2 69x7' `� O a ROPOSED H-20 D/H _ ( �: DISTRIBUTION BOX .,t�� � APPROVALS ARE REQUESTED FROM 310 CMR 15.221 7 . )__ '12" OAK 6 x8' oi�`i .•• ,� t� C Medium-Coarse Sand (1.) A 3.00'WAIVER(3.00'-6.00') FOR THE MAXIMUM COVER OVER THE LEACHING SYSTEM. w _. + • 2.5Y 6/6 (2.) A 2.30'WAIVER(3.00 -5.30')FOR THE MAXIMUM COVER OVER THE DISTRIBUTION BOX. 69x \ GARAGE DOH/`'� (3.) A 1.53'WAIVER(3.00'-4.53')FOR THE MAXIMUM COVER OVER THE SEPTIC TANK. � SLAB=69.7'± ��7' 8.2- LOCUS PLAN X X TP 1 H/ ,- D�N� SCALE: 1"= 1000' LEGEND rn 69x8 DR_ D E z 0 A y 120" 59.80' G) x m w �...._--- _.__. _ No Mottling, Standing or Weeping Observed 50xO EXISTING SPOT GRADE MAP 251 v 69x6' `mow_ Lij z BLOCK 104 x ��GAS w�-W z DESIGN DATA - - - 50 - - - EXISTING CONTOUR LOT H00 / x Z x' �--� to i x 3) DECK GAS`\ w- w `� 4� 50 PROPOSED SPOT GRADE (6 (2 ��� - _ T E T PIT DATA I X O NUMBER OF BEDROOMS (ASSESSOR) 4 ! PROPOSED CONTOUR I--X-X-X-i ,70x2' o #129 NUMBER OF BEDROOMS(DESIGN) 4 __ I 75, EXISTING �� GAS p PERC NO. 14837 --E�E�- EXISTING UNDERGROUND ELECTRIC LINE / 1g.7' DESIGN FLOW 110 GAUDAY/BEDROOM 16 OAK / "`� 4-BEDROOM \, W INSPECTOR: David W. Stanton, RS GAS 1 / O 69x DWELLING cv O TOTAL DESIGN FLOW 440 GAUDAY �- EXISTING GAS LINE \ TOF=70.0'± a EVALUATOR: Michael Rmentel, EIT, CSE R C BFE=67.5± Q DESIGN FLOW x 200 % = 880 GAUDAY C.S.E. APPROVAL DATE- Oct. 1999 _w W---.----W_ - EXISTING WATER LINE TI C P 1) / USE PROPOSED 1,500 GALLON SEPTIC TANK DATE: September 8, 2015 69 x _ _. PROPOSED 1,500 GAL. 16" OA TEST PIT#: 2 TEST PIT LOCATION H-20 SEPTIC TANK 69x8 ELEV TOP= 69.70' O O O PROPOSED 1,500 GALLON H-20 SEPTIC TANK Benchmark ` MAP 951 INSTALL 3 - 500 GAL. H-20 CHAMBERS W/ STONE ELEV WATER= < 59.70' CICComer of Conc. Wall CON 11,942 S.F.± �O PERC RATE _ <2 min./inch PROPOSED 4 SOLID SCHEDULE 40 PVC PIPE Elev. =70.00 14" PINE WALL �, I SIDEWALL CAPACITY CS Approx. M.S.L. S °� ❑ PROPOSED H-20 DISTRIBUTION BOX � / � W (LENGTH + WIDTH) (2 SIDES) (2 HIGH) (0.74 GPDlS.F.) = GAUDAY DEPTH OF PERC= HC-2 � Q (33.5'+ 12.83')(2 ) (2' ) (0.74 GPD!S.F.) = 137.1 GAUDAY TEXTURAL CLASS: 1 �O PROPOSED 500 GALLON H-20 LEACHING CHAMBER 8" OAK 0 w BOTTOM CAPACITY Z 3 (LENGTH x WIDTH) (0.74 GPD/S.F.) = GAUDAY 0"f J (33.5'x 12.83') (0.74 GPD/S.F.) = 318.1 GAUDAY 69.70' TOTALS: Fill _3 REV. DATE BY APP'D. DESCRIPTION __-._ _ _- _ TOTAL NUMBER OF CHAMBERS PROPOSED SEPTIC SYSTEM UPGRADE N77° 16, 10„W TOTAL LEACHING AREA 615.1 SQ.FT. 119.95, TOTAL LEACHING CAPACITY 455.2 GALJDAY 48" 65.70' PREPARED FOR: CAPEWIDE ENTERPRISES LOCATED AT i i NOTES: MAP 251 _ C Medium 15 o 6a6e Sand 129 LONGVIEW DRIVE 2 LOT 88 CENTERVILLE, MA 02632 1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF EACH - - - -- ---- SEPTIC SYSTEM COMPONENT. SCALE: 1 INCH = 10 FT. DATE. SEPTEMBER 16, 2015 �► 0 5 10 20 40 FEET 2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF THE N OF n4gq PROPOSED LEACHING SYSTEM TO ENSURE CONSISTENCY WITH TEST PIT DATA ___.___-.� o ,, PREPARED BY: SHOWN ON THIS PLAN AND TO ENSURE NO GROUNDWATER ENCOUNTERED ABOVE RESERVED FOR BOARD OF HEALTH USE JOHN L. JC ENGINEERING INC. ELEVATION 56.00'AT TIME OF INSTALLATION. REPORT TO ENGINEER AND LOCAL 120" 59.70' CHURCb JR.I LL I: , BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. No Mottling, Standing or Weeping Observed No 418 7 2854 CRANBERRY HIGHWAY 3). ENTIRE PROPERTY IS LOCATED WITHIN THE GROUNDWATER PROTECTION EAST WAREHAM, MA 02538 SITE PLAN S ' OVERLAY DISTRICT AND THE ESTUARINE WATERSHEDS. - �_ _5O$.273.0377 _ ii SCALE: 1"= 10' Drawn By: JC T Designed By:MCP Checked By:JLC _ JOB No. 3235 L___._ _ - -____.� - -----_�'__. _- __� _- _