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HomeMy WebLinkAbout0019 MARCHANT'S MILL ROAD - Health `19:Marchant's Mills Road , Hyannis 0 I i� /11/i'de[L[G® yz NOS 215_CR HASTINOS,UN i i �— i `' � c�� � S`'� �L "T � � V q r a�� - ago Commonwealth of Massachusetts V"5 R1 P0A7- - Title 5 Official Inspection Form- f; Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 19 Marchant Mill Road Property Address §9 Joe Imbriglia T.. Owner Owners Name4 information is Hyannisport MA 02647 12-1-17 required for every :per page. Cityfrown State Zip Code Date of Inspection i5H. 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 C 69QQ filling out forms S� �a. ���Mtuuillu<<nl, on the computer. 0�� �SF.�F.MASs9 use only the tab 1. Inspector: �� key to move your : JAMES cursor-do not James D.Sears use the return Name of Inspector :c5 R ;y key. Capewide Enterprises �,•._o�_ <<o, r Company Name s��� T!'TTF}.•Gl i�s sp�����.�`' 153 Commercial Street utuumra� Company Address Mashpee MA 02649 Citylrown State Zip Code 508477-8877 S1623 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �. 12-1-17 spector'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 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. *M"*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.rloc•rev.6116 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I. a5ed xe� dH I,L:00 L 60Z b0 080 t Commonwealth of Massachusetts Una"ME Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owners Name in formation f is Hyannisport MA 02647 12-1-17 reqguiredred 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 is a 1000 Gal. Tank D Box and pit. 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Z a6ed xed .dH I,L:00 L 60Z b0 080 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe imbriglia Owner Owner's Name information is required for every H annisport MA 02647 12-1-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)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.doc rev.W6 71t195Ofriasl Inspection Form:Subsurface Sewage Olsposal System-Page3of 17 6 a5ed xed dH WOO L IOZ b0 0__0 Commonwealth of Massachusetts Title 5 Official Inspection Form lu Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Merchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every Hyannisport MA 02647 12-1-17 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: ❑ 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 Zona 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 coiiform 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 is less than 6" below invert or available volume is less than day flow P. I t5ins.doc•rev.SMS Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 t7 a5ed xed dH 1.1,:00 L 60Z b0 OaG Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is Hyannisport required for every MA 02647 12-1-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or 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 fift. 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 H 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. Gns,doc-rev.WI S Title 5 Official Inspection Form,Subsurface Sewage Disposal system-page 5 of 17 5 a5ed xe:1 dH 6 6:00 L WE b0 3a0 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every Hy annisport MA 02647 12-1-17 page. Cityrrown State Zlp Code Date of InspWion 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? ® Cl 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 NIA) ® ❑ 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)1310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 6 of 17 9 a5ed YPJ did 1,V00 L I.OZ ti0 X)0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name requiratfo is Hyannisport MA 02647 12-1-17 required for every page. CitylTown State Zip Code Date of Inspection D. System Information Description: 1000 Gal. Tank D Box and pit. Number of current residents: 4 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 years usage (gpd)): 2015-11,000Gals 2016-2,400Gal's Detail Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day igpd> 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.doc-rev.SP5 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of W L a5ed xed dH 1,WO L XZ b0 0-10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P • 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information Is Hyannisport MA 02647 12-1-17 required for every -- 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: NA 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 1/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5'ins.doc-rev.ytg Tltle S official Inspection Form:Subsurface Sewage Disposal System-Pape B of 17 8 abed xeJ dH 2 WO L 1,0E b0 �80 Commonwealth of Massachusetts 'IMP Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every Hyannisport MA 02647 12-1-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1985-Permit # 85 -503. 11-2017 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Bullcling Sewer(locate on site plan): Depth below grade: feet Material of construction: t ❑ 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.): Pipeing is 4" PVC SCH -40. Septic Tank(locate on site plan): Depth below grade: 23"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: 1000 Gal. Precast H-10 Sludge depth: 2" l5ine.doc•rev.6l1e Title 5 Ofllclal hnspectw Form:Subsurface Sewage Disposal System•Fogs 9 of 17 6 abed xed dH Z WO L 1,U b0 Oa0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every Hyannisport MA 02647 12-1-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(oont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Plan-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and outlet cover at 23"below grade w/inlet cover at 8", In and outlet tee's. No sign of leakage or over loading. 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.doc•rev.6116 Title 5 Official Inspection form.Subsurface Sewage Disposal System•Page 10 of 17 o 6 abed xeJ dH U00 L LN b0 080 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every Hyannisport MA 02647 12-1-17 page. CityfTown 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.doc rev,6/16 -ills 5 Ofrdal Inspedon Form Subsurface Sewage Disposal System•Page 11 or 17 stied xed dH £V00 L 60Z b0 M0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe imbriglia Owner Owner's Name information is required for every Hyannisport MA 02647 12-1-17 page, City!'rown State Zip Code Date of Inspection D. System Information (cont.) Distribution.Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note rf box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-28"below grade wlone line out. 11-2017 New D Box w/cover at 8". I 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.doc rev.6AS ThW5 Offidal Inspection Form.Subsurface Sewage Disposal System•Page 12 of 17 el, a6ed xed dH £6:00 L 1,0E ti0 Xi0 t Commonwealth of Massachusetts Title 5 Official Inspection Form �} Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every Hyannisport MA 02647 12-1-17 page. Cityrrown Stale 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.): Leaching is a H-10 1000 Gal Precast pit wl2' stone. Pit at 14"below grade in red brick drive way. 6"water in pit.Wall's clean like new. Note: Bricks were removed. Timber frame w/planting and bushes now over pit area Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.5115 Tifle 5 Official Inspection Form:Subsuriace Sewage Disposal System•Page 13 of 17 £l, a6ed xeJ dH £l•:00 L 602 t O 380 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is Hyannisport MA 02647 12-1-17 page-i for every Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins.doe•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 �6 abed xe� dH t,6:00 L X2 t0 :20 r Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name nformation is required for every. Hyannisport MA 02647 12.1-17 r 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 1:51ns.doc•rev.6116 Tllle 5 Official Inspection Farm:Subsurface Sewage Oisposel System•Pepe 15 of 17 56 abed xe:1 dH t,6:00 L 1,0E b0 DaG j mPRr A�r MILL RP �R►ck O 0 Q. R�l i7 �oilEs Rom - 1y "') 96 abed xe� dH tb WO L 60Z IV0 :)aa r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every Hyannisport MA 02647 12-1-17 Page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells _O Estimated depth to high ground water: 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 Ian reviewed: 10-25-84 g p Dale ❑ 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: T.H. on Design plan 10-25-84 184 no G.W.. Bottom of pit at 7r-2r'below grade. Bottom of pit at 11'above T.H. Depth Before filing this Inspection Report, please see Report Completeness Checklist on next page. l51ns.doc-rev.6/16 Title 5 official Irepecdcn Form:Subsurface Sewage Disposal System•Page 16 of 17 L l, abed MPJ dH b 6:00 L 60Z V0 DaG Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is MA 02647 12-1-17 required for every Hyannisport page. City/Town State Zip Code Date of Inspedion 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 15ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 91, abed xej dH 9 6:00 L 60Z b0 Oa0 No.v' ` Fee 5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppfltation for MieipoSal *pstem Construction 13ermit Application for a Permit to Construct( _) Repair(X Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 19 MAPC3Ro .J"('`5 GK ILA—14.0 Owner's Nanle,Address,and Tel.No. (-�1�drjejt.S 5AR.4" s 70K6J SMNZ(QrUA Assessor's Map/Parcel (a(p ®�® i( "f n4s C©j j'T P rr7 Installer's Name,Address,and Tel.No. 502—q7?—$!R'77 Designer's Name,Address,and Tel.No. dAV&W t?>C EuT (Ss5 53 O ZE' N 1A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) NS7#L_L_ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of ealth. Signed Date 9^a l n,2 l Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 1 Date Issued ` 1 No. 7— Fee ✓ s"" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: J Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 401hation.-for,Disposal Opstetn Construction 3permit Application for a Permit to Construct(Q Repair(X Upgrade( ) Abandon( ) ❑Complete System KIndividual Components f Location Address or Lot No. 19 MA.Qt40gXT'% !mot 1LA_kt) Owner's Name,Address,pnd Tel.No. (-��li4.xJlUts 5APA" S T0k1V rM9XR(QrUA Assessor's Map/Parcel a&(. Qt3b 3(( T1148ft. C00I 'T J>Vr7 '�� PA Installer's Name,Address,and Tel.No. 502-4 7 T=411977 Designer's Name,Address,and Tel.No. ,� _er4 vt�ta�D� E"luTeac�c•�se� � �A1 S3 trcF c a 4G, S-' kv(,!Nog ' , Type of Building: Dwelling No.of Bedrooms •Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil �Kp Nature of Repairs or Alterations(Answer when applicable) tyS7ri4-G Date last inspected: Agreement• The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in y; accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. M Signed Date " 4 . Application Approved by Date x Application Disapproved by. Date for the following reasons Permit No. Q/ J Date Issued t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certifirate of Compliance _ THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�) Upgraded( ) Abandoned( )by CA PC w r oc: E 1 a Al S6 S at t q G t ARO-RAXIT S k 14-C A.13 14%4 has been constructed in accordance with the provisions-of Title 5 and the for Disposal System Construction Permit No AD/ 3P dated 1 Installer (!APE iLb,5 alL kis S Designer NI, #bedrooms Approved design flow gpd The issuance of this permit shall n6tt be construed as a guarantee that the system will fim tc iomas d'esigited. _ Date `��! I Inspector '`,��� ------------ No. y! '"_ ' �� Fee I THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction i3ermit Permission is hereby granted to Construct( ) Repair()() Upgrade( ) Abandon( ) System located at 19 M A kQ_0A )7 r S AFL(L c k) 14 Yes and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with + Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this perm( t. Date � � � t Approved by. two i �tTkzjftd Town of Barnstable Barnstable Regulatory Services Department 1 edcac j HAPNSMASS Public Health Division i634, `0 m ��aN4°Ya 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CT CERTIFIED MAIL#7015 1520 0000 1967 7481 October 3, 2017 IMBRIGLIA, SARA& JOHN 311 TIMBER COURT PITTSBURGH, PA 15238 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 19 Marchant Mill Road, Hyannis, MA was inspected on 09/11/2017 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Need to relocate driveway or move leaching. Distribution box is needed. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF E BOARD OF HEALTH s C ean, R.S., Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\19 Marchant Mill Road Hyannis.doc Town of Barnstable Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA-02601 Office: 508-862-4644 Richard Scab,Director FAX' 508-790-6304 Thomas A-McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TOREPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An`x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground M . ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE(1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA q Single Cesspool- Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) o Leaching pit or cesspool with high liquid level,<12"below inlet (per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: a\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc , 1 , -C\- Commonwealth of Massachusetts cNr(0— D3 O Title 5 Official Inspection p on Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y n� 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every Hyannlsport P/ MA 02647 9-11-17 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When ti A. General Information filling out forms S/4 /a S 9 9 ���NNnnrruyp� on the computer, pW,,11ACIFU4 -LN use only the tab 1. Inspector: ONN�ko' ........ �p key to move your `'O? . JAMES •% cursor-do not James D.Sears �; key,the return Name of Inspector ? x Capewide Enterprises t/fI I I Company Name � S�F1fTI Its 4 ! t •4 153 Commercial Street o'�„ 5 INSPtin ' Company Address ^� Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 16.340 of grnN x a� pp agTitlp/eg[6(310 CMR 15.000). The system: Lily a '4jL9 � •e ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9iai17t,e.1- 9-19-17 Img�ector'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 has a design flow of 10,000 gpd or greater,the insp6g$br 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 appr5ving authority. -r: ""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 conditionsof use. t5ins.doc•rev.6116 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 VV �� i, a5ed YU dH ZUZ L I.OZ 6 dDS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information required for every Hyannisport MA 02647 9-11-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont,) Inspection Summary:Check A,B,C,D or E/always complete all of Section D Al 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: Con Pass-D Box-H-10 Pit in driveway. The system is a 1000 Gal. Tank D Box and pit. Need to replace D Box. H-10 pit in drive. Need to replace w/H-20 or remove that part of drive way, B) System Conditionally Passes: ® One or mcre.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): 15ins.doc•rev.eH 6 Title 5 Official Inspectior ram:Subsurface Sewage Disposal System•Page 2 of 17 Z abed xeJ dH U ZZ L 60Z El, daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owners Name information is required for every Hyannisport MA 02647 9-11-17 page. CIty/Town State Zip Code Date of Inspection B. Certification (Cont) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): Replace D Box. Replace leaching or remove part of drive way. ❑ 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 t5iwdoc-rev.6116 Tltla b Official Inspection Form:Subsuelaee Sewage Disposal Syslem•Page 3 of 17 6 a5ed xed dH ZEZZ L60Z 66 daS t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Marchant Mill Road Property Address _Joe Imbriglia Owner Owners Name information is required for every Hyannisport MA 02647 9-11-17 page. Citylrown State Zip Code Date of Inspection B. Certification {cant.} 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 aseptic 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 f ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded I or clogged SAS or cesspool ❑ ® liquid depth in 4000 is less than 6" below invert or available volume is less than %day flow A,-r t5ins.doc-rev.6116 Title 5 Ofidal Inspection Form:Subsurfsoe Sewage Disposal System-Page 4 of 17 t7 a5ed xeJ dH U?Z L60Z 66 d@S Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every Hyannisport MA 02647 9-11-17 page. CityfTcwn 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 forma ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ® 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 11 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.doc•rev.6116 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 5 of 17 5 a5ed xed dH ZEZZ L 60Z 6l, daS f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every Hyannisport MA 02647 9-11-17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ 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): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6116 rule 5 OKciel Inspedion Form Subsurface Sewage Disposal system-Page 6 of 17 9 a5ed xed dH U ZZ LOZ 6l, daS Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Disposal Sewage Dis g p System Form Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name Information is required for every Hy annisport MA 02647 9-11-17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1000 Gal. Tank D Box and pit. Number of current residents: 4 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 years usage(gpd)): 2015-11,000Gals 2016-2,400Ga1 s Detail Sump pump? 0 Yes Z No Last date of occupancy: Present Date Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersonslsq,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: tSins.doc•rev.6/16 Title 5 officiai Inspection Forth:Subsurface Sewage Disposal System-Page 7 or 17 L abed xe:1 dH ZEZZ L 60Z 61, d8S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form• Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbrigilia Owner Owner's Name information is required for every Hyannisport MA 02647 9-11-17 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: NA 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): t5ms.doc•rev.6116 Title 5 Offidal inspection Form:Subsurface Sewage Disposer System•Page 8 of 17 9 a5ed xeJ dH ££ZZ L60Z 66 C18S Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owners Name information is required for every Hyannisport MA 02647 9-11-17 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: 1985-Permit # 85-503. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. Septic Tank(locate on site plan): Depth below grade: 23" 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: 1000 Gal. Precast H -10 Sludge depth: 211 15ins.doc•rev.6/1e THe 5 Official inspection Form:Subsurface Sewage OiWsel System-Page 9 of 17 6 a5ed xed dH EEZZ L LOZ 6 L daS Commonwealth of Massachusetts Title-5 Official Inspection Form TO Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Marchant Mill Road i Property Address Joe Imbri lia Owner Owner's Name information Is H annisport required for every - Y MA 02647 9-11-17 page. City/Tcwn 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 28" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle $ Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt- Plan -Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and outlet cover at 23" below grade wlinlet cover at 8". In and outlet tee's. No sign of leakage or over loading. 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.doc•rev.NIS Title 5 Official Inspection Form:Sutuurface Sewage Disposal System-Page 10 of 17 0l, a6ed xe:1 dH EEZZ L60Z 66 d@S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every HY annisport MA 02647 9-11-17 __ page. CitylTown State Zip Code Date of Inspection D. System Information (cant.) 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.doc-rev.W16 Title S Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 L I, a6ed xed dH VEZZ L 1.0Z 6l, daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every Hyannisport MA 02647 9-11-17 page. Cityrrcwn State Zip Code Date of Inspection D. System Information (cont,) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-26'below grade w/one line out. Wall's are none. Need to replace Box, 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, Sall Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: t5ins.doc•rev,6116 Title 5 Official Inspection Faro:Subsurface Sewage Disposal System-Page 12 of 17 Z a6ed xeJ dH b£ZZ L60Z 66 daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every Hyannisport MA 02647 9-11-17 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 Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is a H-10 1000 Gal Precast pit w/2'stone. Pit at 14"below grade in red brick drive way. 6"water in pit.Wall's clean like new. Need to replace leaching or remove drive over pit. 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.doc•rev.6116 Title 5 Oflic al Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 EL abed xeJ dH b£:ZZ L 60Z 6 6 XbS Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every H annisport MA 02647 9-11-17 _ Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. t5ns.doc-rev.er 6 Title 5 official Inspection Forth:Subsurface Sewage Disposal System Page 14 of 17 b l, abed xezl dH SEZZ LOZ 61, daS A � y4l S `re 1 o O � pq ` rq ' e Z RA . � � 56 abed xeJ dH 9NE LV 66 �5 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every Hyannisport MA 02647 9-11-17 page. CityrTown State Zip Code Date of Inspection D. System Information (cunt:) 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 a. tsins.doc-rev.6116 Title 6 Officiel Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 9l• a5ed xeJ dH S£:ZZ L60Z 66 daS ' t e Commonwealth of Massachusetts -- Title 5 Official Inspection Form IML Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Mo 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owners Name information is required for every Hyannisport MA 02647 9-11-17 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Na Estimated depth t high ground water: 1 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: 10-25-84 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: T.H. on Design plan 10-25-84 18'+ no G.W.. Bottom of pit at T-2" below grade. Bottom of pit at 11' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 L 6 a5ed xeJ dH 5£ZZ L I.OZ 6 6 daS Commonwealth of Massachusetts Titie 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Marchant Mill Road Property Address Joe Imbriglia Owner Owner's Name information is required for every HY annisport MA 02647 9-11-17 page. Citylrown 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 cf Sewage Disposal System either drawn on page 15 or attached in separate file t5ino.doc-rev.6/16 Title 5 Otficial Inspection Form Subsurface Sewage Disposal System-Page 17 of 17 g a6ed xed dH 9EZZ L 60Z 6l, daS g 9 j0 T_ m MAY 14 1999 N F �-� COMMONWEALTH OF MA > EXECUTIVE OFFICE OF EN IRON NTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 19 MARCHANTS MILL RD. HYANNISPORT Name of Owner JACQUELINE BARR Address of Owner: 2878 NORTH EAST 24TH COURT FORT LAUDERDALE 33306 Date of Inspection: 4/26/99 Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: n/a Mailing Address: n/a Telephone Number: n/a 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 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 The Inpection is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the inspection.My inspection does _ Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:4/26/99 The System Inspector shall iubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 MARCHANTS MILL RD.HYANNISPORT Owner: JACQUELINE BARR Date of Inspection:4/26199 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is levelled or replaced Wa 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 revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 MARCHANTS MILL RD.HYANNISPORT Owner: JACQUELINE BARR Date of Inspection:4/26/99 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 IN ACCORDANCE WITH 310 CMR 16.303(1)(b)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 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa_(approximation not valid). 3) OTHER Wa revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 MARCHANTS MILL RD.HYANNISPORT Owner: JACQUELINE BARR Date of Inspection:4/26/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described 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 X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n1a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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 ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: _ 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 19 MARCHANTS MILL RD.HYANNISPORT Owner: JACQUELINE BARR Date of Inspection:4126/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X r., 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. X 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.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 11 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 MARCHANTS MILL RD.HYANNISPORT Owner: JACQUELINE BARR Date of Inspection:4/26/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-440 g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: 44Q Number of current residents:Q Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): MQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):YES. Water meter readings,if available(last two year's usage(gpd): Wa Sump Pump(yes or no): NQ Last date of occupancy: Wa COMMERCIAL/INDUSTRIAL Type of establishment: n& Design flow: Wa gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):�LQ Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):MO Water meter readings.if available:n& Last date of occupancy: n& OTHER: (Describe) nta Last date of occupancy: Wa GENERAL INFORMATION PUMPING RECORDS and source of information: DLa System pumped as part of inspection:(yes or no):NO If yes,volume pumped Wa- gallons Reason for pumping: n& TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: 1986 Sewage odors detected when arriving at the site:(yes or no): t)LQ revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 MARCHANTS MILL RD.HYANNISPORT Owner: JACQUELINE BARR Date of Inspection:4/26/99 BUILDING SEWER: (Locate on site plan) Depth below grade: ZZ" Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) n[a SEPTIC TANK: X (locate on site plan) Depth below grade: 1 : Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ n(a Dimensions: L 8'6"H 6'7"W 4'10" Sludge depth: 1• Distance from top of sludge to bottom of outlet tee or baffle: M Scum thickness:Q Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: Q How dimensions were determined: MEAS HIED 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 AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n/a Dimensions: n& Scum thickness: Wa Distance from top of scum to top of outlet tee or baffle:ia/a Distance from bottom of scum to bottom of outlet tee or baffle nbi Date of last pumping: n(a 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.) n& revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 MARCHANTS MILL RD.HYANNISPORT Owner: JACQUELINE BARR Date of Inspection:4/26/99 TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Wa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) D& Dimensions: nLa Capacity: n& gallons Design flow: Wa gallons/day Alarm present: NQ Alarm level:jV& Alarm in working order:Yes—No—: NO Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND, SYSTEM IS FUNCTIONING PROPERLY, PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): MQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 MARCHANTS MILL RD.HYANNISPORT Owner: JACQUELINE BARR Date of Inspection:4/26/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/A Type: leaching pits,number: LEACH PIT-FROM ASBUILT leaching chambers,number: 13La leaching galleries,number: 1lLa leaching trenches,number,length: nLa leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: n& Name of Technology: -La Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY SHOWS NO SIGNS OF FAILURE DID NOT EXPOSE COVER PIT IS UNDER BRICK DRIVEWAY. CESSPOOLS: _ (locate on site plan) Number and configuration: Wa Depth-top of liquid to inlet invert: nta Depth of solids layer: Wa Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions:n& Depth of solids: nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 MARCHANTS MILL RD.HYANNISPORT Owner: JACQUELINE BARR Date of Inspection:4/26/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a qA 5 A4 Iti AC tib a I 1 �g D'�, 0C revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 MARCHANTS MILL RD.HYANNISPORT Owner: JACQUELINE BARR Date of Inspection:4/26199 NRCS Report name: Wa Soil Type: WA Typical depth to groundwater: nla USGS Date website visited: n& Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health Checked FEMA Maps Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 r, ^' v y y A I\, Z v 'S N r — a Z N � � Z I� �• � . '; N M � ` N C n, y v v v rim N 0 ,1 r" V f, _3c Z Q I W I. J r i ItIo.... _P", �` Fss.�..... ...�......_. TH OMMGNNEALTH OF MASSACHUSETTS BOAR® OF HEALTH .--.O F.......................................................................................... Appliration for Disposal Works Tonstrnrtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System a 2y1.: ` � j 7 71Jl.. �1t e ''/ ® --------------------------------------------- a Lation-�Addre s /e .......... f ......................................... Owne Address •-••.................. ---------- ... ........------------------....--------------------------------......Installer Address d / E Type of Building �a Size Lot--__•--_dSq. feet Dwelling—No. of Bedrooms.... 4 __________________________Expansion Attic ( ) Garbage Grinder VIV 44 Other—Type of BuildingcSL!?Z4-.4F. /L`Y No. of per'sons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ...............................- . W Design Flow............................................gallons per person per day. Total daily flow.......................N,-15 `17........gallons. WSeptic Tank—Liquid capacity-/_--gallons Length................ Width................ Diameter................ Depth................ 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....•..... ® ,aa Test Pit No. 1___ minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. ? ...minutes per inch Depth of Test.Pit..................... Depth to ground water........................ �+ .......................... ....... ..................... ...... ......_..... O Description of Soil-------------•--------••----••- ----- -----------------•-- I�-�,t�.a.�M �------ -- ---- --=-- `'"�----------------------•--.._...-•------------- U ........................................................................................................ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable_____ Agreement: The undersigned agrees to install the aforedescribed'"individual Sewage Disposal System in accordance with the provisions f iIT 5 the St itary Code—The undersigned further agrees not to place the system dp u ti once has been issued y the board of heal Signed................... ..................... ......... --•--•---••••-• ----- .......•... n Date plicate pp oved By................ -•... •• ••....... = "! - ---..._ 2 1 ......... Date Application Disapproved for the following reasons:................................................................................................................. -•---•---------------•----...--------------------------------......--------------._....---•-•••--••--.--- Date PermitNo......................................................... Issued-....................................................... Date z, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - ------------------------------------------OF.----....................I.,............................................................. for Dhipoiial Workii Tomitrurtion rrrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ...2W ............................................ Location-Add re or Lot No. 4?s o,. . ....... 40---- ........................................... wr Owner Address ......... .. ... .......... ... .... eo.v.................................................................... Installer Address Type of Building Size Lot........- sq. feet U A;Pw ...............Expansion Attic Garbage Grinder Dwelling No,�' f`:Bedrooms.��----_ ....... ............. `13 �VA)44 JW/4/No. of persons____________________________ Showers Cafeteria A4 Other`—L Type' 6`i "uiidi'14' Otherfixtures ............................................................................................................................................... Design Flow..............................................gallons per person per day. Total daily flow-----------_------------ttjW---------gallons. 1:4 Septic Tank—Liquid capacity.,/O"gallons Length________________ Width______.____.__.. Diameter____.-....._.___ Depth_________.___.-. Disposal Trench—No_.................... Width___._.______._______ Total Length_.__._____._.___._._ Total leaching area....................sq. ft. � r, Seepage Pit No_____________________ Diameter____._..__._.__._.__ Depth below inlet___.__..__...._.._._ Total leaching area..................sq. f t. her Distribution box Dosing tank 'colation Test Results Performed by_____________________ ......... Date........... Test Pit No. L. -minutes per inch Depth of Test Pit____________________ Depth to ground water__________________.____- (14 Test Pit No. D niinutes per inch Depth of Test Pit-------------------- Depth to ground water......................:­ ------------------------------------- ------------- ... .... ... .. -- --------- ----"---------------------------"------------------------ Z . . .. ? i� 0 tv4vt...4 4...-1 e��. . ..... ............................................. Description of Soil.................................4/_Ielc� .........A ---------------- ----------------"------------------------------------------------------------I----------------*--------------*------------*--------------------------------*-------------- -- -----------------------------------------------------------------------------------------------....................................................................................................... U Nature of Repairs or Alterations—Answer when applicable....... ................ 4%--------------------------------------------------------------- ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of e State ani ary Code—The undersigned further agrees not to place the system jx opeiation until rtifi e o is e has been issued by the board of health. l k9r_ Signed...................................................................................... ................................ Date Appca ve ......................... ............. ......... Date Application Disapproved for the following reasons:.............................................................................................................. .................................................................. ............................................................... .................................................................. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................................... OF..................................................................................... (9rdifirtite of Toutpliatta THIS IS TO CERTIFY That the Individual Sewa e DisposaliSyste constructed or Repaired by* ..... .. ....................................... .......................... ......... . Installer at.-------- ... . ...... ...... ......... has been installed in accordance with the provisions of TITLE 5 0�t State Sanitary Code as described-in the f application for Disposal Works Construction Permit No._.._.__<­' _­._1EPZ...... dated- .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A=EE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. i .'DATE....................... .......................... Inspector NV�9 .....1� ............ . ........... .......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , ...................._0F...................................................................................... N FEE....... Permissionis hereby granted---------------- a,.We-A- ----------------------------------------------------------------------------------------------------- i to Construct Repair an 1n(ivfdual--S_e-w�W DISR)* al System at No. 40? Ys -- e -------------------------------- St t as shown on the application for Disposal Works Construction �e_rffite No... ted..... ----------------_______ _------ ------ - - ----------------------------- Board of Health DATE....................C FORM 1255 A. M. - i I N 9=f=iJ o e �( ,S-oolS,f 1 i orb � z 27- �r r ev 9 PT1.vtoo S ex.;. i 3 ✓3rz �fop�sc{ 16 Dc�r� . l IN L OT- d N N ,y-Z,w,J c.✓<F�'rr:/� �' �)SM Cx N ,\ 7'AM< � \ anon VLC-a CJ� � ,- elT L !I -- - 1T` 1 r ` i ;� L-Xrsn�c /Z F-/ w ti I oT- 10 F/Zrj-r 1.lA2o €T I cA— / \\ (1 I Il rrSAD RG7�1n� 5 �+3HG(c C -rZc...'N �ZN OF`d7gSs i I dS54'/YIt_P. PRo7L-cT ON NBERG r' 1Z /�Y'✓Ir E�;• No. 366 ; r, hr LEGEND of,d s CERTIFIED PLOT PLAN :XISTING SPOT ELEVATION Ox0 :XkSTING CONTOUR --- O - -_ p—i. -IP� ISHED SPOT ELEVATION O.O ;{ �% �,.� r�`y'' L_or T -' 'INISHED CONTOUR - 0 — k= . t 3 I'Jc _.,F; 1�1�u,<.�F rlrti ;sPD. 1 N APPROVED , BOARD OF HEALTH /�'cvisc,� GATE ^� AGENT " . SCALE: _ '-;.� ' DATE ] FL DRE®GE ,ENGINEERING CO. IN CLIENT NKKc;;F I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. e4r BUILDING SHOWN ON THIS PLAN CIVIL LAND DR. ��� CONFORMS TO THE ZONING .LAWS ENGINEER SURVEYOR OF BARNSTAB Lf , MASS. 712 MAIN STREET CH. BY: po t H YA N N i S, MASS. F SHEET...L OF ..,.-, DATE REG. LAND SURVEYOR p + t /MOTE /Fi�EITNt:'�! T//E.S�PT/C TAN�C OR AO FT. M//V. LE/fCN/wG P/T r4NE ^ioR4- TN AN /Z"'®El-Olt/ GRA DE,A Z,4•p/AM E.T.ER CO/yG'R�TE FOYER lk SJlA L L &,F 6 moCAOR T WO GRA O.E.64 N E,t'T'RA Q~PVC o/P� 100•DD C:ON�ETE J`/EAYy C^ST/RO/Y CC►yER Si/ALL BE USEa COVERS M/N. P/TtN /F //y pR/VEyVAY /B PER FT. I 2'�L M/N. j CONCR'L'TE _ a .�oE CO Y�R CLEAN SANG .•. i BACXI=/LL e •ate „ LQu/D LEVEL • -• • •: - / „y 4; $(NEDtJL640 �,;. 2*1AYER ?i �{bCG P/PE IO OtU Jw w MIJv.plTc.*f GAI.. 1 • . . • • .� SEPTIC TANK D/ST, e • • 1 • • is • s • # A, • a • yyA SHFO STONE BOX A, 11 $ • . • • • � .�� • . o••' 1 1 oEf-FECT/Yl' 1 ' . •` 3�4 - At �/2 `: • o 1 • DEp7-N • • • • • o WASHE0 STONE i r. . • o • • • • o • • •• PRECAST SEE.�GE lNrGJtT C'LE✓ATIONS 1E'is•Sy2•�= �7/•ZS • �•� � • • ;• • • • • �s '�'c�v p 7 OR EQ[l/v. //vYERT AT QulLD/NG 47 S FT 7e S x i •J = 7 S C.Fr DIAM. 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G7 GROUIVO WATER AT ELEV. i JOAD IVO. dri/E.ET��' 1 2 3 4 5 8 7 B 9 10 :►,= EMBR ARCHITECTS K Al K EMBR Architects,LLC 37 Derby Street,Suite B-1 1 Hingham,MA 02043 (781)556-5282-EMBRARCH.COM -DN.2 GRADE J J DECK G STEP ON. �I ! vCOVERED DECK II { H II II I H STEP ON. 1 I 1 —BENCH--, —— ___ ______ _____ ____ DN. IIL-�— BUILT414 lems ___ -- -- r r1� 1 1 L-- J I `'a� I S I R! L j J 1/2 BATH ¢E�y• ?4 D72 I LINE OF BREAKFAST AREA STUDY 1I — 112 Z CEILING ABOVE I� 712.7 G LIVING ROOM p t+o M n+ G WALTHAM 107 ©I i� �i KITCHEN LLg4S I 1 109 �W D AI 107.1 1 — PROVIDE POWER AND CABLE I CONNECTION FOR T.V,THIS — LOCATION,COORDINATE - WITHOWNER EXISTING BACK OF O c IIDN BUILT-IN TO REMAIN CLOSET gaol i J �. i PANTR 1 100 REF. I I I -- NEW WINDOW IN EXISTING GRADE DS _ OPENING TYPICAL FOR F GRADE -- . F - � .................... I ___ __ I ROUGH OPENINGS TO BE $ I I I RELOCATED I MEASURED IN 7HE FIELD BASEBOARD HEAT, `�` -- O ANO VERIFIED WITH j GB FOYER VERIFY IN FIELD 1 � 113.1 PROPOSED WINDOWS 101 109.3 + 109.2 109.1 UPI I I I GAUVREAU RESIDENCE I ® A301 j PROVIDE POWER AND F1 y-1 FORCAB TV*ONNEQT CONNECTION j LISLE WIN a202 1'-0' LOCATION, ON. CENTERL BETWEEN WINDOWS LOCATION, 13R DOOR TO � 1 a COORDINATE WITH ALIGNED A7 E a203 DECK OWNER CENTERL STONE EDGE,COORDINATE a202 i E j I ORMER WITH OWNER GARAGE FAMILY ROOM — I RENOVATIONS O 7 33 19 MARCHANT'S MILL ROAD, 106 Al I II HYANNISPORT,MA a3o2 O I I I I.I I 113.5 I BRICK FIELD.COORDINATE I I OWNER: I I WITH OWNER I I ANDREA GAUVREAU -- RECESSED LIGHTING(X3) a2o3 I I 19 MARCHANTS MILL ROAD, INFILL DOOR I IN ROOF ABOVE,VERIFY I I HYANNISPORT,MA ` DETAILS WITH OWNER D - L- ---- - WALK IN OPENING 102.+ T I I • CLOSET L — —113.t— — D PAD WALL AS REQUIRED O AREA OF NEW 105 TO ALIGN NEW GYPSUM I 3'6' LANDSCAPING — — NEWWALL COORDINATE HAROW00 TYPICAL BOARD. EXISTING INFILL WINDOW OPENING WIHOWNER7 `713.4 ` 113.3 k--EXISTING DOWNSPOUT LOCATION, INTERIOR AND EXTERIOR FINISH FLOOR S TO TOMATCHEXISTINGED OR$AND WINO S 1 HARDWOOD EXTERIOR WALL ER,TYP. j. l ` I TYPICAL,NEW DING LOCATIONS 7' 4 1. L————————————— BE REUSE EXISTING LOCATIONS INFILLTCH TY TYPICAL BEDROOM 1 702 NEW2X6 { — Al IAi ' RECESSED LIGHTING(X3)IN ROOF A-30+ 2'-V C.O. --_. - ..-. I A�01 ABOVE,VERIFY DETAILS WITH OWNER C DOUBLE STUD BETWEEN• WINDOWS 702.2 ELEVATIONS LTRANSOM E SOMWNDOW ABOVE DOOR,SEE C INFILL WINDOW +�+ OPENING LINEN =_- -- m 1 05/30/18 FOR CONSTRUCTION a4 1 axER IGN NO. DATE REVISION/DESCRIPTION I 702.4 102.3 RELOCATED /f'� EQ. EQ. BASEBOARD HEAT, PROJECT NO:18.0008-GAUVREAU (Ib IB VERIFY IN FIELD - CAD DWG FILE: �fJ § BATH 1 F 103 - DRAWN BY: I TILE 1oa.1 CHECKED BY: B I EXPOSED SIDING BETWEEN B WINDOW TRIM AND CORNER/ CORNER BOARD TO BE EQUAL SEE EXTERIOR ELEVATIONS 033 !'. FIRST FLOOR F, PLAN A-201 A PROJECT A NORTH FIRST FLOOR PLAN -T-0• A-101 8 1 2 3 q 5 6r 7 B 9 10 n ' 1 2 3 4 16 6 7 6 9 10 EMBR ARCHITECTS p.y0, EMBR Architects,LLC- 37 Derby Street,Suite B-.1 Hingham,MA 02043 i (781)556-5282-EMBRARCH.COMIK - BALCONY 1 I I I I BALCONY 2 - - ------------------------------ —- —— - CLOSET q O 209 I 2,1.1 $No.20136 2m.1 I BEDROOM3 CLOSET BEDROOM 207 L+_=J uc 212 211 1 --- — — _ CLOSET BATH - 0 zofi 2,0 9fl 212 CLOSET COORDINATE DOOR SIZE IN FIELD TO MAXIMIZE SIZE = -I -- -- r4j- / WITH CLEARANCES TO SLOPED CEILING F // F — I' DIMENSION IS FROM 0 ' HALL FINISHED FACE OF - 201 EXISTING WALL TO -/-�I - --- CENTERLINE OF NEW WALL --- -- ------- �'_ - I i F1 GAUVREAU RESIDENCE II I � I I A-202 E - A-203 206.1 r_ I = --It o DIMENSION ISTOEDGE q-2p2 Ii �i E OF FINISHED FLOOR � RENOVATIONS __J L J 19 MARCHANTS MILL ROAD, Al BATH 2 I 1 1 I� _- --I I zo1.1 A, I W�k-in closet HYANNISPORT,MA A-302 - -- I � I Ly II 206 I 1/ I A'302 213.3 I 213 I IL Y J I w l OWNER: NEW COPPER ROOF — ANDREA GAUVREAU 1 BELOW CLOSET CLOSET l A-2o3 i 214 E z13, 19 MARCHANTS MILL ROAD, HYANNISPORT,MA o - i CLOSET _ i i —— — ——— ID 204 1 L--- I BEDROOM2 I� 203.4 A, Al Qy. ROOC.'ELoW Not Doing roof over garage door - q-3o, --�-- I CLOSET AaD1 „ C ' I 205 05/30/18 FOR CONSTRUCTION I I DATE REVISION/DESCRIPTION 203.3 I 203.2 EXISTING HEADERAeOVE _ - OJECT NO:18-0008-GAUVREAU TRANSOM W NDOW To D DWG FILE: I I I REMAIN,NEW WINDOWS TO I 8E HELDTOEXISTING AWN BY: I HEADER JAMB AND SILL TO I BE INFILLED TO CREATE ECKED BY: 8 1 NEW ROUGH OPENING - _- SECOND FLOOR F, PLAN A-201 A3 PROJECT A NORTH SECOND FLOOR FLOOR PLAN PLAN , i A-102 2 3 4 5 B 7 6 9 10 y