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HomeMy WebLinkAbout0008 MARCHANT'S MILL ROAD - Health 4 `A'Mardha 'Vis lill`Road Hyannis a Siu UPC 17734 # No. HASTINGS,ON TO%3vrN OF B;:: i+STr"R Lrl i.C�`_.A''1101v tnA� N7S fnt(G SEWAGE # VILLAGE �YRNNl�S rdefl ASSESSOR'S MAP& LOT � _D t I, INS fALLER'S NAME&PHONE NO. -14 YQ,%�� 0eu?. ,rii.rn ed. SEPTIC TANK CAPACITY QV SV" (& D�G�L )evc!/1 - LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNER "T C070V&4 zkL51r PERMPIDATE: 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 A \on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist i withi.,300 feet of leaching facility) Fee, Furnished by �� VVV o a P Commonwealth of Massachusetts ru Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I'0 M 8 Marchants Mill rd `> Property Address 0 l'-f. Michael R Scotti Trust EX, Owner Owner's.Name information is i—' required for every Hyannis Port Ma 02601 9/17/18 page. City/Town State Zip Code Date of Inspection _r Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information (3h 33 a,q filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain ,Q Company Name 35 Content Ln Company Address Cotuit Ma 02635 City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below Is true, accurate and complete as of the time of the Inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/18/18 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 page. Cityfrown 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: System contains a 8x8 Cesspool as well as a 1,000 GI leach pit. Water level in cesspool does not appear to have ever been as high outlet pipe. Staining in cesspool has only been 2ft from the bottom. System is like new. 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): �I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 l5ins•3/13 P 9 P Y 9 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation'by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 L Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,••'�r 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e s . Number of times pumped: PP ( ) P P ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large,system.has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form :a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ❑ Has the system received normal flows in the previous two week period? r art of Have large volumes of water been introduced to the system recentlyo as ❑ ® 9 Y P this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 f Commonwealth of Massachusetts w W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is Hyannis Port Ma 02601 9/17/18 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information Description: System contains a M Cesspool as well as a 1,000 GI leach pit. Water level in cesspool does not appear to have ever been as high outlet pipe. Staining in cesspool has only been 2ft from the bottom. System is like new. I Number of current residents: Seasonal Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 172 Gpd 9 ( Y 9 (9P ))� 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None provided Cesspool is dry 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): Single cesspool with 1,000 GI leach pit .I l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I �• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,•'"r 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 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: 30 + Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): -- Depth below grade: 1.5feet 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.): i Septic Tank(locate on site plan): Depth below grade: Cover to grade feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date i l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 �• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•''p 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Marchants Mill r d Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Na 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.): Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 j f Commonwealth of Massachusetts Tiro- t e 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 8x8 Depth—top of liquid to inlet invert Dry Depth of solids layer Dry Depth of scum layer Dry Dimensions of cesspool 8x8 Materials of construction Brick Indication of groundwater inflow ❑ Yes ® No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 page. Cityrrown 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, Y p 9, 9 , etc.): No ponding no break out Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 �• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 page. CityfTown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 9/17/18 page. Citylrown 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: 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: Usgs maps indicate ground water at 10+ft 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 9/18/2018 Assessing As-Built Cards . � v oWC4 Vw OF BARNSTABLE LOCATION ? (jf_ � SEWAGE,# VILLAGE p� j' ASSESSOR'S MAP& LOT INSTALLER'S NAME& PHONE NO. Q cow, �0..t/7C SEPTIC TANK CAPACITY /OLD LEACHING FACILITY:(type) ��lf(�(r 3r57�r1 (�) /000 NO.OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER , !G BUILDER OR OWNER Alke SCl1Tfi! DATE PERMIT ISSUED: A_2_pp DATE COUPLIANCE ISSUED: S-/0-RIO VARIANCE GRANTED: Yes No_V i ,fkx•5F i TANk ' lava Ovwm , 3 ' http://www.townofbamstable.us/Assessing/H Mdisplay.asp?mappar=266029&seq=1 1/2 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis annis Port Ma 02601 9/17/18 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 117 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System,Form - Not for Voluntary Assessments M 8 Marchants Mill rd Z Property Address i0 Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port ✓ Ma 02601 5/30/16 page. City/Town State Zip Code Date of Inspection d6 .. Abb. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information �# on the computer, J/ //(P3 use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Company Name 8 Johns path Company Address S.Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 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 L cal Approving Authority 5/31/16 I pector'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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 l V3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner ,wt Owner's Name requiratifo`_e Hyannis Port Ma 02601 5/30/16 required for.:every y 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: System contains a 8x8 Cesspool as well as a 1,000 GI leach pit. Water level in cesspool does not appear to have ever been as high outlet pipe. Staining in cesspool has only been 2ft from the bottom. System is like new. 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 5/30/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): El 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Marchants Mill rd .,M 9 Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 5/30/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other.' 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 1/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 5/30/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or 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 El El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 5/30/16 page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done.. You must indicate."yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available a able note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is Hyannis Port Ma 02601 5/30/16 required for every Y , page. City/Town State Zip Code Date of Inspection D. System Information Description: System contains a M Cesspool as well as a 1,000 GI leach pit. Water level in cesspool does not appear to have ever been as high outlet pipe. Staining in cesspool has only been 2ft from the bottom. System is like new. Number of current residents: Seasonal Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 163 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts ry . r!A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is H required for every annis Port Ma 02601 5/30/16 Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None provided Cesspool is dry 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): Single cesspool with 1,000 GI leach pit t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 5/30/16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 30 + Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.).- Septic Tank (locate on site plan): Depth below grade: Cover to grade feet Material of construction: El 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 5/30/16 page. CityrFown 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 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 How were dime nsions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 5/30/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 5/30/16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Na 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 5/30/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 8x8 Depth —top of liquid to inlet invert Dry Depth of solids layer Dry Depth of scum layer Dry Dimensions of cesspool 8x8 Materials of construction Brick Indication of groundwater inflow ❑ Yes ® No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 L t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 5/30/16 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 ponding no break out 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 6/9/2016 Assessing As-Built Cards C QWr,OF BARNSTABLE LOCATION SEWAGE # - VILLAGE / F�'f ASSESSOR'S MAP& LOT INSTALLER'S NAME& PHONE NO.�YOtr6 Crjff"- SEPTIC TANK CAPACITY /000 LEACHING FACILITY:(type) f� � 3 �� (size) 1600 NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Mjjq�- f DATE PERMIT ISSUED: -A-$g DATE COUPL1ANCE ISSUED: VARIANCE GRANTED: Yes No (/ ► ptr 1 3 http:/Atvww.townofbarnstable.us/Assessing/H M display.asp?mappar=266029&seq=1 1/2 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 5/30/16 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. °M A 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 5/30/16 page. Cityfrown 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: 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: Usgs maps indicate ground water at 10+ ft Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Marchants Mill rd Property Address Michael R Scotti Trust Owner Owner's Name information is required for every Hyannis Port Ma 02601 5/30/16 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t ; : TOWN OF BARNSTABLE C.0M.Wt�yy� LOCATION �I 1'��U_ (�I�.n SEWAGE # VI R R� I.Y:AGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE No.A Q6 cJm'r, '6 � Ad SEPTIC TANK CAPACITY LEACHING FACILITY:(type) z pj'r :3"5 (size) lC JO NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER[ G BUILDER OR OWNER Nltj DATE PERMIT ISSUED: - -�� DATE COUPLIANCE ISSUED: 9—`0 VARIANCE GRANTED: Yes No V ii i r IIL r� J Fes/ No.-- THE COMMONWEALTH OF MASS ACHUSETTS 9j BOAR® OF HEALTH l� Appliratiaan for Uiipnia1 parks Towitrurtuin Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..... - ...AA ( I /�i�L 12�� . ........................................... ---••--• n------ ------- -------------------- � �''" (cation-Address .or t Vo. ...... ........ -. Owner Address a 1 o E �M5 SH f Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms;_--_--3________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building •___________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures _________________________________ _ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 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.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by.......................................................................... Date...................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-___----_--_________--_ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit-_-____.____________ Depth to ground water------------------------ J. ............. •••........ T... ODescription of Soil....../ ---------- --.® 1`�1 ........................................................................................... x W ------------------ ................................--•----•--------•---------------••-•••••-•----••------•-••••----------------•----••-•---------•-------•----------•---------•----•----•••-•-•••••-•-- UNature of Repairs or Alterations—Answer when applicable...._ __ _ `� ----------------------------------------------------------------------------------------------------•--••--.. -- _._©vl, er/ t ' Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with TT r1"^ the provisions of TT of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bepq issued by t and health. r Signed •• - ----- . ----_---_-_-------------- Date Application Approved By------------f�-�.. •---.................................. .=16 Date Application Disapproved for the following reasons:-------•--••------------------•••--•••••-•-----••--•---••...--•--•--•--••---------•-•-•••-----•••-•----------- �-------------------••---...---•------••-.....••••---••-••-•-...-..-••-......----------....-....-------.....•---------•---•---•--•-•------•---•--------•------••---•---•••••--••••--------------••-•----- Date Permit No-----F.i...... �•------------------------ Issued_..................- ................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------- -------- -- -------------------OF..................................................... App ire tion for Dhipasal Works Tonstrnrtinn Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal �w System at: Location-Address Zr or t tio. _Owner Address �J �� �i 1. .....+rJ✓��' .................................................. ............. Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.._.._._................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type of Building No. of persons............................ Showers a g ---•--•--------------------- P ( ) — Cafeteria ( ) dOther fixtures .............•--•------------------------------------..--••••••••-----------•--•---•••••----••--•-•--••---------------•-•......---•-••-------------••- W Design Flow............................................gallons per person per day. Total daily flow..........................................._gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area........._........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1.-_______________minutes per inch Depth of Test Pit.................... Depth to ground water--_________-_-...._____- rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ x Description of Soil-----! ' ��n �� ........C/�/ij ................................... U ••••--••---•-••----------•-•••----------------•••.......-••--•--•••-•••-•••....-•••----------•-----•--•---•----••-•••---._...---------••••-----•---••---•-------•-•••--•-•-••-••---------•--•------•-... W ---------------------------------------------------------------------------------------------------- -------------------------••----•-•••••------••••---------------•--••-•••--••------••.............. 0 Nature of Repairs or Alterations—Answer when applicable....__rr_.._``...................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I.LT1 a. p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by t and : health. Signed Date Application Approved BY----•--••••• � Date �5 APPlication Disapproved for the following reasons-------------•-----------------------------------------....---------•---------------------------•----............ -•-------•••--••••••.......••-••-•-••------••••-•--•-•-•-------•--••-•••••---------------••--••-----...----•-••--------------•------••-••••-•-•--------•-••...-•--•-------•--•-•-----••••-••------------ Date PermitNo..... - - ` ?......................... Issued_..................- ................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ._ r::......oF...............1/ ., � ............................ Trrtifiratr of Toutplinnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired Q\X� by------------------ ._...:..� fLy .c. staller ............. has been installed in accordance with the provisions of TITLE 5 of "I'hlie State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_..--_.-._._._____--.-__-______-----•_---___-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................:.. �J..:. ............................ ......... .....�)......................................................COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .. .:. :r.z:�...........OF............../ � .. ,....... /�.�. . FEE.. �:, ... �►tn�r�an�t1 nrk� �unn�ruan lernti# Permission is hereby granted.............. -��-��.^•.. .....--•��� e, C---------•---•-------------------------------------------------•-•---•--- to Construct ( ) or Repair (-.) an Individual Sewage Di osal System atNo. mil ..-•-- �.... .A.4----- � le., ::.,t� ✓1•-------•------------------------•---•-- Street r% Dated....................................•..... as shown on the application for Disposal Works Construction Permit No._ 3 !� ------------------•--------- ------- .._...Board of Health DATE-----------....... ................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS I � � t1�ar end S (��\� � , ,��S � ' ��� TQWN OF BARNSTABLE = UNDERGROUND FUEL AND CHEMICAL •STORAGE REGISTRATION- �, OWNER AND INSTALLER I NFORMAT I.ON, ADDRESS: u. t! d tot h4 t/LMill fib -_ H_AP_NO_. - :''b " PARCEL NO.Rwo OWNER NAMEk 044171/ t1 1 a VILLAGE h AVA/15 coe� INSTALLATION: DATE: BY: - ADDRESS: C :r �� CERT. 0. ;N TANK INFORMATION LOCATION OF.rTANK: w li / _ f��� (.� t� `.-(/ . (•`�' (JfU'6/ CAPACITY ' _ TYPEr , AGE FUEL/CFIEMICAL TESTING CERTIFICATION 3 PASS/ C . ]FAIL DATE LEAK-DETECTION _ , 1 X] CHECK ;IF N/A t: TYPE/BRAND ZONE OF, CONTRIBUTIONS C¢4]f YES C ]--NO DATE TO BE REMOVED q,"� FIRE DEPT. PERMIT. I SSUEDL C ] YES7 NO DATE ',+' � ..a�ti1! _...�.._......._.,..........-.. '�', r- J f (L''' r, UNSERVA i ION"" C CHECK CIF N/A- DATE BOARD OF HEALTH`"TAGt-NO"-.0 31 ]C ]C ] DATE ' 1 MAIL., PLEASE PROVIDE~A---SKETCH SHOWING THE, TANK LOCATION ON THE BACK OF THIS CARD c� AFTER FIVE DAYS RETURN TO: M. R. SCOTTI P.0.BOX 225 WINCHESTER-MASSACHUSETTS 01890 G 1 M. R. SCOTTI ' P. O. BOX 225 WINCHESTER, MASSACHUSETTS 01890 (617) 729-9200 Date 0 �� ��/tVy►.Q���sA Subject R7/ l MMEDIATE REPLY ❑ NO REPLY .REQUESTED NECESSARY Z / Signed . ......... ned Date RECIPIENT RETURN PINK COPY Reorder from Business Envelope Manufacturers*'Pearl River,N.Y. 10965 • Item No. NF-12 W R. S O / I P 0, Roy 2205 Datel" t 4 �Y y Subject . j rfrMMEDIATE REPLY ❑ NO REPLY / REQUESTED NECESSARY mazza Js N K. Signed r , Si74 ed .Y Date+ I RECIPIENT: DETACH AND RETURN THIS COPY TO SENDER—FOLD MARKS FOR STANDARD WINDOW-ENVELOPE. t Reorder from Business Envelope Manufacturers• Pearl River,yl.Y. 10965 • Item No. NF-12 V *THE T TOWN OF BARNSTABLE � ! .�. OFFICE OF i BARISTLU t nuti639 BOARD OF HEALTH >�o D Y�Y 367 MAIN STREET HYANNIS, MASS. o26oi tot, 19 8 3 Dear Enclosed is brass valve tag number68__ _ . Please attach this to the fill pipe of your underground tank. You must do the following as indicated : _____ Remove your tank . I have enclosed information for you regarding removal. ___ Have your tank tested starting now. You must test during the .10th, 13th, 15th, 17th and 19th year and annually thereafter. Removal--by the year_------- . I have enclosed information regarding the testing of your tank. * To have it tested you must first contact one of the listed engineering companies to have a monitoring well installed. This is a one-time installation fee of $150-200 approximately which is good for the life of the tank . Once the monitoring well has been installed you must contact the Barnstable County Health Department at 362-2511 , extension 334, and .talk to Charlotte Stiefel . Ms . Steifel will arrpnge to do a free test, known as soil vapor analysis , for your underground tank. This, test will indicate to us the status of the tank. _ Due to the unknown age of your tank we must presume that it is twenty (20) years of age. You must have it tested every year and remove it by 1993 . Please follow procedure for testing as indicated aT�o�ve from the * on. If you have any questions please feel free to contact me at the Town Health Department, 775-1120, extension 183 . S cerely, a Donna Miorandi j { Q ' grit o L u Ita ci aep4rznanx I-A Box 534 iyan"nip MA OZ601 Tag The C �rnata 't. ' i4ea( Th 0(1 are. enc N�•y/Ai} Or �d�rC hen-cot) y�4-- Or-4()Q tank h4a 9C ticen tcstO4 'I a� rye 0 You ore dirocted Vp hava Ioc# tusk *no itt 94#4nq test.€ * uith1n• thfrt C;W) '.Oays oyyppfry� re.}t:etiv{t�+�s��"•:�hy��y�:y;:� y�t(���t. y���y.Result�.s�}6f the t"In"g, sheaf ba' f:Ik ? with t o ,7V ti/ be Hi• ltt6! Rile, th FI14'i, 400af tm-ent& i �yryi y,�I��j y�y��.iy 4y that p y�y,�'y �ti .# y'!. �y i�i yI� yy�y�R its ,�y :.�4 �y ,,�i♦♦.e l: #. �p 'You a\ 'RT. • omf oldFi that y'N r s ha t t have the tanh fait y 1 t s ,ju i p. ing Vast ed 4du �6� t ha- lottt,r 13th* I t'ho 17tho 0 19th yC r a#t'O in t �t nd . silo annualtY t.hereaftor.. use ` say rye .lucst. tteorih if. a wri.tton .japti ion re-luasting samo is �rec-cured . i) Eb C)oar' 3#; 'A.: A11 1,t 9 vet°. . days alter %bi s Q*tder i,s-, e7'V;doi 5'e'r 7ZOII At et,Ow P 0 sox 22' WINCH,ESTCR "A I1890,