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Home My WebLink About0004 MARCHANT AVENUE - Health 4 Marchant Avenue,Hyannis A= IF I I o �I i N� Commonwealth of Ma r AA �a� ssachusetts l"I a(0 - Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments. a /V 4 Marchant Ave Property Address _- Liz Ellerton =s- .4 ,_W Owner Owner's Name information is H annis Port ✓ Ma 02647 9/26/15 ` required for every y _ _ - page._ City/Town State Zip Code Date of Inspecion 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 -- - fillingoutforms A. General Information on the computer, i use only the to 1. Inspector: key to move your cursor-do not Michael DiBuono use the return - ---- - - -- --------- ---- key. " Name of Inspector ` f. *..•. `DiBuono Sewer and Drain_ c_ ,,.. €r�r �� rab t •Company Name -- 8 Johns path Company Address - rarorn .. S Yarmouth —.---._.._..-------- _ MA, ., " 02664 +•`a- = City/Town State Zip Code --------- 508-364-9587 S113522 Telephone Number License Number iC 1.,C-ertificati6n 1 certify that I have'personally inspected the sewage disposal system at this address and that the information reported below is trl1e; 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 9/26/15 R Inspector's 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 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. /w VIS t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal�Vs�mpage 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Marchant Ave Property Address Liz Ellerton Owner Owner's Name information is H annis Port Ma 02647 9/26/15 required for every � - --- -- --- ------- -------- - ---— - — -------- 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: - 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: The system contains a 1500 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several leaching gallies and at time of inspection levels appeared to never have been at abnormal levels. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form �= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °. 4 Marchant Ave Property Address ----- -- — — ------------------------------------ Liz Ellerton _ Owner Owner's Name information is required for every Hyannis Post` _ _ lVb' 02647` 9/26/15 page. CityFrown 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-Co•nditionalty Passes--(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Tille 5 official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Mar chant c t Ave Property Address ---------------- --- --------------- Liz Ellerton ---- -- ---------- -------- ------ ------------------------ caner Owner's Name information is required for every Hyannis Port _ Ma 02647 _ 9/26115 page. CityFrown 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: r. ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used,to determine distance: "* This system passes if.the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Marchant Ave Property Address Liz Ellerton_ Owner Owner's Name --- -------- --- -- — — information is required for every Hyannis Port _ Ma 02647 9/26/1.5 _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) .Yes No El _ Required pumping more than 4 times in the.last year NOT due,to clogged or ® obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high groundwater elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 f Commonwealth of Massachusetts Ville 5 . fficial Inspection Fr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Marchant Ave ------- -- ---------------- —---_ --------Property Address Address Liz Ellerton Owner --- ------------------ Owner's Name — — information is required for every Hyannis Port _ _ _ _ _Ma 02647_ _9/26/15 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-- El❑ ® 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): 5----- Number of bedrooms (actual): 5 ----- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 550 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for 9 p Y Voluntary Assessments 4 Marchant Ave Property Address Liz Ellerton Owner Owner's Name -- information is required for every Hyannis Port _ Ma 02647 9/26/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1500 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several leaching galleys and at time of inspection levels,appearedto never have been at abnormal levels. Number of current residents: -------------- Does residence have a garbage grinder? ❑ Yes ❑ No Is tau-ndry 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 224 GPD — -- 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: --- --- -----------------------.—.---- Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): -- --- --- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — -- -------------------- 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal.System Form Not for Voluntary Assessments 4 Marchant Ave Property Address Liz Ellerton Owner Owner's Name information is Hyannis r ort Ma 02&47` 9t26/15 required for every — -----------------.._..- -- -- page. City/Town State Zip Code Date of Inspectio ------------- n D. System Information (cont.) Last date of occupancy/use: date ------ - Other(describe below): General Information Pumping Records: Source of information: 2001 , 2014 — — Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: -. -------- -- ---------------------- gallons How was quantity pumped determined? - ---- ---- Reason for pumping: — ----------------------- Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): 151ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Marchant Ave Property Address Liz Ellerton Owner Owner's Name --- -- — ----.--- ----.-.---- information is required for every �yannis Port _ _ Ma 02647 9/26/15 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: 11/22/95 install date Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 18" --- -- 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.): System is vented throught the roof__— Septic Tank (locate on site plan): Depth below grade: 1 ft __ — —--- — feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gallon __ —_ ----- -- _---- 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: --------- __-- t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \a �` 4 Marchant Ave Property Address ----- Liz Ellerton Owner Owner's Name -----------— ---- — --- information is Hyannis Port Ma 02647 9/26/15 required for every —y ------ -------- ----__--- -- -- --- — -- -- page. City/Town 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 3 -- — ---- — Distance from top of scum to top of outlet tee or baffle 42" ------ Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge_stick_ How were dimensions determined? Tap_e Measure _ -- Comments (on pumping recommendations, inlet and`outlet tee or baffle condition,'"Structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: NA 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 t Commonwealth of Massachusetts Title. 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Marchant Ave Property Address --------- ------....------------------------ ---- --- ---- --- Liz Ellerton Owner Owner's Name information is 9/26/15 Hyannis Port'" Ma 02647 _ required for every _y _ page. City/Town State Zip Code Date of Inspection D. System information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: — -- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: - —--------- ------ ---- Capacity.- -- — ------------— gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: --- -- Alarm in working order: ❑ Yes ❑ No Date of last pumping: date Comments (condition of alarm and float switches, etc.): --------------- *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 15ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts y W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \. 4 Marchant Ave a Property Address --" ------- Liz Ellerton Owner Owner's Name — information is required for every Hyannis P'ort'__ _ _ _ Ma 02647 9/26/15 _ page. Cdy/Town ---------------- State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth-of 4iquid level above outlet invert At normal level... 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.): Distribution Box is level and at normal level with no signs of carry over or decay.__ 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: ISins•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 /pt 4 Marchant Ave Property Address ------ Liz Ellerton Owner Owner's Name -- --- ---- ------- --------- --- ----- ----- - information is required for every Hyannis Port _ Ma _ 02647" "-" " 91261T5 page. City/Town State Zip Code Date of Inspection- D. System Information (cont.) Type: ❑ leaching pits number: -- ----- -- ❑ leaching chambers number: -- -- ---- ® leaching galleries number: 6 ----- — ❑ 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.): No si ns of carry over and no signs 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 a Commonwealth of Massachusetts Title 5 Official Inspecti-on Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \or 4M s archant Ave Property Address Liz Ellerton Owner Owner's Name --- — - information is required for every t!yannis Port` -_-_ -_ Ma 02647 9/26/15 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.): No signs of ponding or hydraulic failure_ _— -- — 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 Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /. 4 Marchant Ave Property Address - --- — Liz Ellerton Owner Owner's Name information is required for every Hyannis Port_________ Ma_ 02647 _ 9/26/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately 15ins•3/13 Title 5.Official Inspection Form.Subsurface Sewage Disposal System•Page 15 of 17 A 2 ' 3 a W f�7• pC54 I i I� Lacrr Li.on: /I MarchanL ilvenue Vi.lIacje _ HyannisporL Septic _ 1500 Gallon SeaLic Tarik. Owner Elizabo- Lh EllerLon PUMPING HISTORY 11/ Ull 1500 Gals Commonwealth of Massachusetts Title 5 Official Inspection Forte Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Y y is 4 Marchant Ave Property Address — ------------------------ -- -- Liz Ellerton Owner ---------- -- ---- ---- —-- - -- -- -----------------—-- ---- ----- Owner's Name - - information is required for every Hyanriis Port —_ Ma 02647- 9/26/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft —_-- 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: 11/22/15 --__ Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data on plan dated 11/22/15 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts 4 —= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Marchant Ave Property Address Liz Ellerton _ Owner Owner's Name ---- ------ -- -- ---- — information is required for every Hyannis Port __- -_ Ma 026.4.7 . 9/26/15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems]-tompieted ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ms•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Executive Office of Environmental Affair s Dept. of Environmental Protection Jolm au One winter Street Boston Ma. 02108 Gt ' D.E.P.'Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI U.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION *Rckwr Property Address: 4 Merchant Ave.Hyannis Address of Owner: Date of Inspection: 116198 (If different) Name of Inspector: John Graci Brian J.Oniell:Telespectrum Woridwide 443 South Gulph Rd.King of Prussia PA 19406 1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name, Address and Telephone Number: CERTIFICATION STATEMENT 1 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x_ Passes This Inspection Is based on criteria defined In Title V _ Conditional) a55 code 310 CMR 16303.My findings are of how the system Is y performing at the time of the Inspection.My Inspection does _ Needs Furt r E uation By the Local Approving Authority not Impyany warranty or guarantee of the longevity ofthe Fails septic system and any of Its components useful life. Inspector's Signature: Date: 116198 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. 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 Coitlpliance(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 exfiltralion, or tank failure is imminent.The system will pass inspection K the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04=97) One Winter Street • Boston,Massachusetts 02108 . FAX(617)556-1049 a Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4 Merchant Ave.Hyannis Owner: Brian J.Onlell:Telespectrum Worldwide 443 South Gulph Rd.King of Prussia PA 10406 Date of Inspection:1I6108 _ Sewage backup or.breakout or high.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to 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 leveled 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(s)are replaced obstruction is removed 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 the public health, safety 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 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: 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 in 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 cesspool. SAS is in hydraulic failure. (revlaed 007187) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4 Merchant Ave.Hyannis Owner: Brian J.Onlell:Telespectrum Worldwide 443 South Gulph Rd.King of Prussia PA 10406 Date of Inspection:115r98 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: _ 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 II 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. (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Add res s: 4 Merchant Ave.Hyannis Owner: Brian J.Oniell:Telespectrum Worldwide 443 South Gulph Rd.King of Prussia PA 19400 Date of Inspection:116199 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: ,c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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 part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)) (revised 04127)971 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4 Merchant Ave.Hyannis Owner: Brian J.Oniell:Telespectrum Worldwide 443 South Gulph Rd.King of Prussia PA 10406 Date of Inspection:115199 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 9•P•d./bedroom for S.A.S. Number of bedrooms: 4 Number of current residents: e Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): Yea Water meter readings, if available:(last two(2)year usage(gpd): rJa Sump Pump(yes or no): No Last date of occupancy: Na COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nra Last date of occupancy: nra OTHER:(Describe) nra Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection: (yes or no)Ne If yes,volume pumped:0 gallons Reason for pumping: Ma TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date Installed(if known)and source Information: 100 years Sewage odors detected when arriving at the site:(yes or no) No trevlaed04127l97) , i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4 Merchant Ave.Hyannis Owner: Brian J.Oniell:Telespectrum Worldwide 443 South Gulph Rd.King of Prussia PA 19406 Date of Inspection:116198 SEPTIC TANK:x (locate on site plan) Depth below grade: V Material of construction:x concreate metal FRP_Polyethylene—other(explain) If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Lio's^Hsr•ws'e^ Sludge depth:+" Distance from top of sludge to bottom of outlet tee or baffle:ze" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle:e" Distance form bottom of scum to bottom of outlet tee or baffle: 16" How dimensions were determined: measured 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.) Septic tank Is structurally sound.Recommend pumping septic system every two years. GREASE TRAP:_ (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rya Scum thickness:rVa Distance from top of scum to top of outlet tee or baffle:rya Distance from bottom of scum to bottom of outlet tee or baffle: rda Date of last pumpingnra 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.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: vv- Material of construction: cast iron x 40 PVC_other(explain) Distance from private water supply well or suction linetown Diameter: 4,_ a Qaimments: (conditions of joints,venting,evidence of leakage,etc.) pevleed 0427187) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4 Merchant Ave.Hyannis Owner: Brian J.Onlell:Telespectrum Worldwide 443 South Gulph Rd.King of Prussia PA 19400 Date of Inspection:116199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: nra Material of construction:_concrete_metal_FRP_Polyethylene=other(explain) Dimensions: nra Capacity: nia gallons Design flow: nra gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) D-box Is Amdurely sound. PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)No Alarms in working order(yes or no)_yea Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) nra (rsvlsed o4r2A97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4 Merchant Ave.Hyannis Owner: Brian J.Onieli:Telespectrum Worldwide 443 South Gulph Rd.King of Prussia PA 19406 Date of Inspection:116199 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: nra Type: leaching pits, number: 1 leaching chambers,number:We leaching galleries,number: nla leaching trenches,number,length: nra leaching fields,number, dimensions:6x4 overflow cesspool,number:No Alternate system: nra Name of Technology:_nra Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) System and all components are structurally sound. CESSPOOLS:_ (locate on site plan) Number and configuration: nla Depth-top of liquid to inlet invert: nla Depth of solids layer: nla Depth of scum layer: We Dimensions of cesspool: nra Materials of construction: rda Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection) nfa Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nra PRIVY:_ (locate on site plan) Materials of construction: nla Dimensions: nra Depth of solids: nra Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nra (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 4 Merchant Ave.Hyannis Brian J.Oniell:Telespectrum Worldwide 443 South Gulph Rd.King of Prussia PA 19400 116198 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) I r> O Page ! of ltl (revived 04)27197) . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C SYSTEM INFORMATION(continued) 4 Merchant Ave.Hyannls Brian J.Onlell:Telespectrum Worldwide 443 Soulh Culph Rd.King of Prussia PA 19406 116199 Depth of groundwater jo. 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 with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS maps and charts (revlsed04)27/97) 1tyo 10 of 10 '_::a'ai�'iZ �'�1 fit'G /-!!).✓T- SEWAGE VpLLAGE �/ �?�y�-i s �o Q % ASSESSOR'S MAP & LOT 99 0214 _t - — li TALLER'S NAME&PHONE NO. /',z If sT 7 7 - `'k SEPTIC TANK CAPACI i Y LEAC'RNG FACIL=: (type) 6 �r l��S'S (size) T X a X NO.OF BEDROOMS " G BUILDER OR OWNER PERMITDATE: 7-1 / COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 I -� � � :� � v 1 g' �� ` � � � 1 � � � �' � � i `� J � ti 4 (% No.. -.. ��. FEa......3.Q.................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiun for Diupuuttl World Tomitrnrtiun Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: 4 MARCHANT AVE HYANNISPORT .............................•-•---••-------•---...-----.....-------------••--................... ••••---------------•----•--••----•-••-•-••--••••------•-••-•-••--•-••-••----•---•...---•-•....---- BRAIN 0 N�Y n_ address _SAFIE or Lot No. ......................--•-----•------------•-----••----•-••--------------------................. ---•-••----------•-•••------••••-••--•••••••---•-••-••........••-••............----------•---••-•- Owner Address a ARCH. CONST' .CO HYA.NN . Installer Address UType of Building 6 Size.Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building No. of ersons---------------------------- Showers ts, YP g ---•........................ p ( ) — Cafeteria ( ) 44 Other fixtures -------------------------------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitv___._-_--_-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 (X ) Dosing tank ( ) Percolation Test Results Performed bY------------ ----------------=•--••--••-------•-------•--•--------•----•-• Date........................................ W Test Pit No. 1----------------minutes per inch Depth of Test Pit...-_-_-.-_-__.-__ Depth to ground water-.--_-.-.---_-_-_-_-__- fi Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water--..-_---_-__---_--_--. 1:4 --------------------------------•-.........------..._........._....--•-•-•-•-•-••-•......._......---......................................................... 0 Description of Soil.................................................................................................................................-...................................... x W UNature of Repairs or Alterations—Answer' when applicable...UPGRADE...T_Q_.-'1!I'j'LE---V......................................... ----- --500---tank-----Dbox--and---6_._g_a_]..]..iea...w1th._.2f-e-e-t...stane_............................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia has been issued by th board of Sign ..._.................._.............. ..... ------------.--------- ---------3./.�_619.5------ Application.Approved B ' ...1......-. .... Due Application Disapproved for the following rear on . ----------------------------------------------------------------------...._. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- ------------------- Permit No. ----------/ ------�I Issued ." <..-.. —e------ I Dare l .................. a < THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diinvijiittl 19orki Tiamitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal ra System at: 4 MARCHANT AVE HYANNISPORT .........................................T..�.•J-----...---...----------------------•---.....-------- ---------------------- ----------------------•---................................ 1. BRAIN 0 1�Iifft1-Address SAME or Lot No. ••-•---•----•--------...................•-••------...-•----------•--------•------------•-•-•----• --•---•--------•--•--•------•-----------------•----...---------------........-•••-......--•------- Owner Address a ARCH CONST. CO HYANNIS -'---------------------------------------------------------------------•--•---•------------ Installer Address Type of Building 6 Size Lot............................Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons.......................... Showers ( ) — Cafeteria a' Other fixtures .......................;.._._._ _ _ W Design Flow...,< ______________________ gallons per person per day. Total daily flow--------------------------------------------gallons. -1-5 00- WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter_-------------- Depth-_,_--_--___-_.. x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No.-._----.._- ...... Diameter..............N___-Depth below inlet-----------------.__ Total leaching area..................sq. ft. Z Other Distribution box (g ) Dosing tank,( ) `4 Percolation Test Results Performed by...............=----...................................................... Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ fir Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ ----------------------------------•-----------------------•--------------------------------.................--•-••--•------...----•-----......------•.....•. 11 O Description of Soil. ...................•-•------.....------------. ...--------------------------•------------------------------------------•......_.. x _ V Nature of Repairs or Alterations—Answer when applicable...UPGRADE-.TO__-TITLE.__V......................................... 1500 tank, Dbox and.••6-•.gallies--with-.-2feet--_Stone Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia has been issuby th board of h lam' Sign ----- Date Application.Approved BY (' c.c_ ... -.......... - .�' ." � --- Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------------------------------- i ......... ........... ................ .........-----------------------------------------------------------------...........----------------------------------------- ---------------------------------------- Permit No. ---------- ......_�1 Issued -*— — /c' Da[e THE COMMONWEALTH OF MASSACHUSETTS.,,' BOARD OF HEALTH TOWN OF BARNSTABLE Certif rate of C�omplinure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by - CONSTO.' - - ------ -------------------- - ---- --------------------- -------- -.-------.. ..--------.--------------- .. ARCH......._ ...... ........ ----------------------------_-----h,�:�u e� - -- - - - _ at -A---MARCHANT...AVE..-HYANN-I-S-POR ------- -- ------------------------ --------------...................------------------- ---------- ------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as descr' ed in the application for Disposal Works Construction Permit No. -..---��-" dated ..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE---- 1... l" -------- Ins e t r ------� - _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.... / TOWN OF BARNSTABLE �".....y��m. FEE .................... Rapmal Nab Tomitrurtion Wrmit Permission is hereby granted. ARCH CONST._..CO to Construct ( )) or Re air ((X ) an Individual Sewage Disposal System 4 MA1iCHAN� AV•E• -------••-•-.HYANNISPORT-•••--- ----------------------------------•------. BRAIN...0-NEIL........ at No. -• -------•--•-- --. Street as shown on the application for Disposal Works Construction Permit NV.—')-'.7�h..___ Dated_� _. __l _-_ '...... -------------------•------ t ------------ -------------------------------•------------ a r Board of Health DATE :_ .^ 7--< `J.................................. FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS 'TITLE 5 CALCULATION CHART REQ 3 BEDROOMS 4 BEDROOMS 5 BEDROOMS 6DROOMS SEPTIC TANK S= 1500 Gallons 1500 Gallons 1500 Gallons 1500 Gallons DISIT MLMON BOX Distribution Box Distribution Box Distribution Box Distr-%ution Box SOEL ABSORPTION SYSTEM (one of the following): Flow Diffusors,W9h One Foot of Stone 7 9 12 14 FW. D•t�,isc� U.-AL TWO ►f;Fr-* vP Stone rj Galleys (4'X 41 With One Foot of Stone l i 14 18 22 Leaching Trench(length X width X depth) 60'X 4'X 2' 80'X 4'X 2' (2) 48'X 4'X 2' (2)57'X 4'X 2' or(2) 30' X V X 2' or(2) 40'X 4'X 20 or(4) 2C X 4'X 2' (4) 28'X 4'X 2' 4'v, capa-kb T c rer+ s+,,- IB High Capacity Infltr=rs With One Foot 1 i 15 18 22 of Stone High Capacity InSkrators Without Stone 16 22 27 32 Leaching Field or Bed 446 S.F. 595 S.F. 743 S.F. 892 S.F. Rroallcl e Sdrs VJ -No ._ F i D� -Class I Soil(OJ4 GP��S F}I 3. e�c t- 5 t�-� arm Pc�-; i- _a. z CL," d„ O -TF,ee— P,cc �tr 33a'% .�b�, '3 5 � 2ra.M� 3 o Pcs..wc�rby Gu l .''' 3.�ce '�Fone. _ . \ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR rr DEPARTMENT OF ENVIRONMENTAL PROTECTION 1 1 1 E ., .-... OFFICIAI.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: q Mat Ct,rci Owner's Name: v 7 A - Ownees.Address: Date of Inspection: I PName of Inspector:(please print) tdi 11 i ash F. Rolm nson Sr. Co.mpanyName: William E. Robinson Septic Service -. Mailing Address: P O Box 1 089 Centerville MA TelepboneNumber:-s081 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this.address and that-the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my raining and experience in the proper finiction maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to S an 15-340 of Title 5(310 CNR 15 000)- The system Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: y if 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 c o tetin tliis ion.If the } ys mp g tnspett� _ system is a shared system or has a design flow of i 0,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be seat to the system owner and copies sent to i e.buyu,if applicable,and the.approying authority. Notes and Comments '—This report only describes conditions at the time of inspection and tinder the conditions of use at that tithe.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I " /"� Page 2 of i! OFFICIAL INSPECTION FORM—NOT FOR`'OLLTNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �i � �(-ek-V4 Owner. M�LDINJ . Date of Inspection. 3` t t e4c>a Inspection Summary: Check A,B,C,D or E/ALWAYS complete ail of Section D A. Syste Passes I have not found any information which indicates that any of the failure criteria described in 31-0 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below_ Comments: B_ System Conditionally Passes-- One or more system components as described in the"Conditional Pass"section need to be re placed 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 folio explain wing statements_,If'bot determined"please 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 ,existing tank is replaced with a complying septic tank as System will Pass inspection if the mA metal septic tank will pass inspection if u suucttually sound,not the d fea-CertiGeate of Compliance indicating that the tank is less than 20 years old is available. ND cxptam: Observation of sewage backup or break out or high static water level in the distribution box due to brakesor . obstructed pipe(s)or due to a broken,settled or uneven distribution box_System will approval of Board of Health): pass iitspeztion if(with broken pipe(s)are replaced obAl"Oon is removed: distribution box is leveled or replaced ND explain: The system required pumping more thm 4 times a year elite to brakes m obstrt'cted P (s)•The system will }pass inspection if(with approval of the Beard of Health): broken pipes)are replaced' obstrnctinn'is;fanovcd ND explain: Page 3 of!! fi. 0!FFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTV�IFICATION(continued) Property Address: - Owner. W_11? . Date of Inspection: r C. Further Evaluation is Required by the Board of Health: Conditions-exist which require further evaluation by the Board o 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 I5.303(i)(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.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: — '1 he 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 will. The system has a septic tank.and SAS and the SAS is less than 100 feet but 50 feet or more froul a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a D£P certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 1 Other: 3 c. lagc4ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �' tQ✓\} � 1va Owner: Date of Inspection: u`1 D. System Failure Criteria applicable to all systems: You must indicate'ycs"or"no"to each of the following far 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 ttte ground or surface waters due to an overloaded or / clogged SAS or cesspool ✓ Static liquid level in the distribution box above,outlet invert due to an overloaded or clogged SAS or �� cesspool _ Liquid depth in cesspool is less than 6"below invert or,available volume is less than%:day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100-feet of a surface water supply or tributary to a surface /water supply: Any portion of a cesspool or privy is within a Zone l 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 1.00% greatcr:than 50 feet from a private water supply well with no acceptable water quality analysis.(This-system passes if the well water analysis,- performed at a DEP certified laboratory,for coliform bacteria and voiatHe organic compounds. indicates that the.well is free-from pollution from that facility the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggeredA copy ofthe analysis°must be attached to this form.( (Yes/No)The system fails.I have determined that one ormore oCthe 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- You must indicate either"ycs"or"no"to each of the following: (Tlte following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ — the system is.within 200 feet of a tributary to a surface drinking water supply - the system is located in a nitrogen sensitive area(interim Wellhead Protection Area-1 WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Sertian E Bw-system is considered a significant threat,or answered "yes"in Section D above the large system has failed,The uwncr 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 s)vem owner should contact the appropriate regional office of the Department- 4 Page 5'of I! OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST " Property Address: ` I�'Ci SC�1C� +1t Owner: Date of Inspection: Check ifthe following have been done_You must indicate`)res"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 I,(/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?, Ywas 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. Yes .no 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(3)(b)) 5 Page 6 of I I - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. /00,f.5 c, _ Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. 6� Number of bedrooms(actual): � DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): . ro(�-o 6�� Number of current residents: C� Does residence have a garbage grinder(yes or no): /V"o Is laundry on a separate sewage system(yes or no):Z;0[if yes separate inspection required] Laundry system inspected(ygs or no): Seasonal use:(yes or no) e1 Water meter readings,if available(last 2 years usage(gpd)): �g Co g - -7ci r �! Sump pump(yes or no): /U.) Last date,of occupancy: COMMERCIAUINDUSTRIAL Type of establishment Design flow(based on 3I0 CMR 15.203): Basis of design flow(seats/persons1sgft,etc_): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available. Last date of occupancy/use.- OTHER(describe): GENERAL INFORMATION Pumping.Records �---_ Source of information: Was system pumped as'part'of the inspection(yes or no):— If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping_ - TYP,R s c Se ti SYSTEM S distribution box,.soil absorption systerri _ _Single cesspool - Overflow cesspool T 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 D£P approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 15 Cl S^- l f'Ceps Were sewage odors detected when arriving at the site(yes or no):11k 6 L Vagc 7 of I OFFICIAL INSPECTION FOIIII1-=N07r FOR VOLUNTARY ASSESSNIEN-FS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA1 PART C . SYSTEM INFORMATION (continued) Property Address: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron "'40 PVC_odter(explaut): Distance from private%cater supply well or suction lint: Cornpietrts(on condition of juutts,venting,evidence of leakage,etc.): SEPTIC TALK: locate on site plan) Dcpth below grade. 1/0 e Material of construction:�oncrete_metal fiberglass_poiyctliylene _ot}rer(explain) — If tank is metal list age:_ Is age confinned-by a Certificate of Compliance(ycs or no):_(attach a copy of certificate) Dimensions: Sludgc.dcpth: ��r Distance from top of sludge to bouont of outlet Ice or ballle: 3 , Scum thickness: d Distance from top of scum to top of outlet tee or baffle: /0r r Distance from bottom of scum to bottom of outlet tee or baffle: /d r` I low were dimensions determined: n rA-e� (cuter -7bo�a a►.,a�.;,,�e..,r,� - Comments(on pumping reeonuncndatrons, iniet and outlet tee or baflle condition, structural integrity, liquid levels as related to oudc( invert,evidence of leakage,ctc_): L�Ic� a,.�t' r,,.�Lf f-c•Ls act- �� Je�c( ��- S� �� a� a1€c��, GREASE TRAP:/v l(ve'atc on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass�ioiyethylene otlicr — (cxplain): -- Dimensions: Scum thickness: distance frolic Iop of stunt to top of outlet(cc or bailie: Distance front bottom of scum to bottom of outlet.[cc or bafllc: Dale of last pumping: C:onunerits(on pumping rcconunendations, utlet and outlet ice or baffle cundtttua,structural integrity, liquid levels as related to outlet irn•crt,evidence of icakagc,ctc_): 3orll OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSUIUACE SEWAGE DISPOSAL SYSTEM INSPECTION FORAI ART C SYSTEM INFORMATION(continued) criyAddress:.•`{ , of laspection: J� lIT or 110LDLNG TANK:/(tank must be pumped at time or inspection)(locate on site plan) h below grade: trial of construction:_concrete_metal_fiberglass___polyethylene other(cxplaut): cnsions: Icily :- gallons gn Flow; gallons/day at present(yes or no): w level: Alann in working order(yes or no): :of last pumping: Lments(condition of alarm and float switcbcs,ctc.): TIUDUTION BOX: present must be o rcacd locate on site plan)l )( p ) �t 0 of liquid level above outlet invert: CJ ranents(note if box is level and distribution to outlets equal,any evidence of solids carUover,.any evidence of age into or out of box,et .) D t-CL-— t�y</�o NIP CHAMBER: j (1 talc on site plan) lips in working order(yes or no): ruts in working order(yes or no): macnts(note condition of pump cltautber,condition of bumps and appurtenances,ctc.): — Page,9 of l i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS f' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner Date of inspection: SOIL ABSORPTION SYSTEM(SAS):Zoocate on site plan,excavation"not-required) If SAS not located explain why: Type _ leaching pits,number:_ — leaching chambers,number_ leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, y� dry S larafe�P �. S'�L.rC 66 ku,=1 cLrz Ina 54— 6A t revzo lJ 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 or 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.): 9 Page 10 of t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. Owner: SJC1 L,2 Date of inspection:_ 3T �y 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. t dr t A _ A 17 �.� 37 : 10 'Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1, SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: ��„�1011WIF SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water S feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS_) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: (ofci.tnc/wvftT t.�cS E'lys/,s�cvt ��+ caCCtdSNe� %�J • 'J� / �✓trfzl-�C (n/ta.�c/u +�cr- 11 ,