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Home My WebLink About0185 MARSTON AVENUE - Health 185 Marston Avenue,Hyannis A= r� Commonwealth of Massachusetts °2 019— 1� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments X) �M 185 Marston Ave Property Address Gregory Bilezikian ;; Owner Owner's Name information is required for every Hyannisport Ma 02601 4/5/2019 : page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, 1 V use only the tab 1. Inspector: ' key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. . DiBuono Sewer and Drain rQ Company Name 8 Johns path Aff Company Address S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by_the Local Approving Authority 4/8/2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every Hannis ort _Y p Ma 02601 4/5/2019 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1,500 GI Septic tank as well as a concrete distribution box and seven flo diffusers. System is functioning properly. 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. I *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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Offi ial Inspection Form c Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every HY p annis ort Ma 02601 4/5/2019 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 y Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every Hyannisport Ma 02601 4/5/2019 page. Citylrown State Zip Code Date of Inspection B. Certification (con t.) t.) 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 p public health safety and environment: p ' ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This if th asses system Y p e well water analysis, performed at a DEP certified laboratory, for fe cal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every Hy p annis ort Ma 02601 4/5/2019 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 I If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every Hy p annis ort Ma 02601 4/5/2019 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week,period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310,CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every HY P annis ort Ma 02601 4/5/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: System contains a 1,500 GI Septic tank as well as a concrete distribution box and seven flo diffusers. System is functioning properly. Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 178 Gpd 9 ( Y 9 (9P ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No I Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every Hy P annis ort Ma 02601 4/5/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2012 2016 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Site glass Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every HY P annis ort Ma 02601 4/5/2019 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: 16 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.): Septic Tank(locate on site plan): Depth below grade: 1.5feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is H annis ort required for every Y P Ma 02601 4/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of leaking,Tees and or baffles in place at time of inspection. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every HY p annis ort Ma 02601 4/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G'M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every H Yannis Ort p Ma 02601 4/5/2019 page. City/Town 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 Level and at normal level. Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No signs of carry over Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is p required for every y H annis ort Ma 02601 4/5/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 7 ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No ponding no break out Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name required for is every H annis ort required for eve Y P Ma 02601 4/5/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No ponding no break out Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, conditioi of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner Name s a e information is required for every Hy p annis ort Ma 02601 4/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information isequired for every H annis ort Ma 02601 4/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 3/10/2000 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is H annis Ort required for every Y p Ma 02601 4/5/2019 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 of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 o"I NJ;i 0/ f58 °N5 e TOWN OF B S E LOCATION ISIS� /At �� ° ! `� - SE AGE VILLAGE fw.T ASSESSOR'S MAP & LO 'S NAME&PHONE NO. INSTALLER - SEPTIC TANK CAPACITY /-noj:�, LEACHING FACILITY (size) Gil NO.OF BEDROOMS BUILDER OR OWNER l e , PERMITDATE: dh COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a { { t • -� CO`NON«-EALTH OF MASSACHUSETTS ExECL-TIVE OFFICE OF E?��%IRON'�4ENTAL AFFAIRS DEPARTMENT OF EN-VIRONN ENTAL PROTECTION ONE WINTER STREET. BOSTON. NIAO'_105 61=-_9. 5C�4- _ 1`Z WILLI AM F.WELD TRLM CO): Govcmc •' = ' �; rokNoF �'ID BSTRi Lt.GEO t.Go crnor CELLL'CCl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORtit h�"WO,pj"4,9, �C�or rniss�cr. PART A _. _, (P CERTIFICATION 5 6 9• ' Property Address; \8S Address of Owner:�q�N�\ �*j�S. Date of Inspection: 1t\s-\k 1q j'`(If different) ' Name of Inspector: c� am a DEP ap roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name:1}/7a 41-7iLr'e En p n,+g we P Mailing Address: Re) tSo,c e_3;�_19�i IHflS q Telephone Number: r_5-e I CERTIFICATION STATEMF'*%T cenii that I have pe,sonally inspected the sewage d!sposal system at this address and that the information reported be!oN is true, accurate and comole!e as o:the time of mspectoo The inspecion was performed based on my training and experience to the proper furicnor, and maintenance o;on-s-te sewage disposa; systems. The system: - ,-, Passes _ Conc+tionaii% Fasses tieecs Furthe- E%-a!uat;or, Ey the local Approving Authorim Fa. s Inspector's Signature: Date: T;ie 5vs:e7 Ins.-,=, sha!' submr a coPe of this inspecion report to the Approving Authorih• within them, (30) days of completing this inspectoor,. If the system is a shared system o• ha, a des,gn floe of 10,000 gpd or greater, the inspector and the syster.. owner shall submit the repo^ to the appropriate red ona) once of the Department of Envtronmenta' Protector.. The orig:na! should be sent to the system owne- and copes to the buyer, if applicable. and the approving authority. ' INSPECTION SUMMARY:, Check A, B, C, or D: AJ SYSTEM PASSES: �l I have not found any information which indicates that the system violates any of the failure riteria as defined in 310 CMR 15.30-. Any failure criteria not evaluated are indicated' below. , COMMENTS: li --- \ T -T t 171, SrA't� 2.t co.h 018 a s S(Ng I OA -�l 047t Ytillt'P wict anus! t Nita v�'gQ*ad.r�u 9 •r N Fv1Z�2-C, -- - .. t . BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, upc completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N. or NDi. Describe basis of determination in all instances. If'not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; c the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tar,' failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank w approved by the Board of Health. lr��:aat 01/25!97) Page 1 of 10 PART A - CERTIFICATION {continued) n. r ._ - - ,f s' ,,, ^d r`Z., is y�i.r 1`t •,�� Property Addr.$ss: Owner: Date of Inspection: - Bj SYSTEM CONDITIONALLY PASSES (continje-d Sewage backup or breakout or high static water level observed in the distrib tion box is due to broken or obstructed pipes) or due to a broken, se*led or uneven distribution box. The system ill pass inspection if(with approval of the Board of Health), Describe observations: _ broken pipe(s) are replaced -- --- . -. •- - obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to br en or obstructed pipe!s).:The system will pass inspection if twith approval of the Board of Health): - -- broken pipets; are replaces - obstruction is removed - - _- C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH Conditions exist which require further•evaluation by the Board of alth in order to determine if the systern is failing to protect the public health. safe'and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMIN S THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or pri%, is within 50 feet of a surface wa r Cesspoo? or prn,, is within 50 fee! of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH ND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THA PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil abs Lion system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water sut:pi•:. _ The system has a septic tank and soil a sorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil sorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soi absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a ell water analysis for eoliform bacteria and volatile organic compounds indicates ft the well is free from pollution fro that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used t determine distance (approximation not valid). 3) _ OTHER (revised C4!25!9-,) Page 2 of l0 SUBSURFA_CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • .._ PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DJ SYSTEM FAILS: You must indicate ether 'Yes- or "No" as to each of the following: 1 have determined that the system violates one or more of the following failure truer as defined to 310 CMR 15.303 Tne oa� !s for this determination is identified below. The Board of Health should be contacted o determine what will be necessary to correc the failure. _ Yes Nd Backup of sewage into facility or system component due to an overt ded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or su ace waters due to an overloaded or clogger S.qS or cesspool. Sta:ic hquid level to the distribution boa above outlet invert du to an overloaded or clogged SAS or cesspoo!. Licu?d depth to cesspool is less than 6" below invert or avail bie volume is less than 112 day tlov. Recurred pumping more than 4 times in the last year NO due to clogged or obstructea pipes. Number o'times pumped _. An, portion o the Soil Absorption System, cesspool prir'y is below the high groundwa:e, eieyatlo- Any por::on of a cesspool or privy is within 100 f t of a surface water supply or tributan- to a surface water Supply. Any porion of a cesspoo' or prn•� is w dhir. a Z ne I of a public we!]. Ara)% pertio- of a cesspool or prnti• is within ' feet of a private water supply well Amy por:.on o:a cesspool or prig-v is less t an 100 feat but greater than 50 feet from a private water supply we!i with nc acceotabie %ate- quart` analysis. If the yell has been analyzer to be acceptable, an,ach cope of we!I water analysis for cohiorm,. bacteria. volatile organic comp unds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: 1 ou must indicate e::he• 'Yes` or "No- as to each of t e following. The fo,.o":rg c-itena aep;v to large system in addition to the criteria above: The system serves a facility with a desig flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public hea!th and safe,) and the enviro ment because one or more of the following conditions exist: Yes No . the System is within 400 eet of a surface drinking water supply the system is within 2 feet of a tributary to a surface drinking water supply the system is locat in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone II of a public water supp well) The owner or operator of any suc system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 d 6.00. Please consult the local regional office of the Department for further information. (revised 04.125/97•) Pad• 3 c! 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSFEIL . .PARI S _`CHECKLIST r Property Address: l95 Mom" ` Owner: 'Subs Date of Inspection: Check if the following have been done: You must_ indicate either 'Yes'or'No'as to each of the following: Yes No .. _ . Pumping information was provided by the owner, occupant, or Board of Health. _ None,of the system components have been pumped for at lea-,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. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facliN or dwelling %vas inspected fo,signs o-*sewage back-up. _ Tne s%-stem does not receive non-sanitary or industrial waste flow. _ The site %%as inspecred for signs of breakout. . _ A!I s-ste.. component:, excluding the Soil Absorption System, have been located on the site. y _ The sea:.c tank manhoies were uncovered. opened. and the interior of the septic tank was inspected for condition, of baffies or tees. material o• construct-on, dimensions, deptn of liquid,depth of sludge, depth of scum, The size a-id locatoon of the Soil Absorption System on the site has been determined based on: The fac,lir, o).•ne• ianc occupants. if difteren: from owner were provided with information on the proper maintenance of Sub-Surface Disposal Svsterr.. Existing information. Ex. Plan.at B.O.H. _ Cie:ermined in the field of an-, of the failure criteria related to Par, C is at issue, approximation of distance is unaccea:ab;e 115.302.3):bil (revised 04/:5/571 Page 4 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATIO% Properh Address: 18S WMSjar/ PeV � Owner: wS Date of Ihspection: co 11 FLOWS' CONDITIONS RESIDENTIAL: Design floe. 330 e.p.d./bedroom for S.A.S Number of bedrooms Number o°current residents-QL . _ _....._. . Garbage g•::der (yes Laundry coy:- , __.. ... ___.._.._......_.__...__. __.._ . ected to system (yes or no . Seasonal use Ives or no!: r-) Water meter readings. if available (last two (2i year usage Sump Pump Ives or not La��da;e o`occupancv COMMER C i 4L'I N D LIST R I Al Type of establishment. Design fio%%. a!ionsida\ Grease trap present. Ives or no Industna! haste Holding Tani; present. Ives or no :on-sanitan %aste dischargeti to the Taie 5 system. (ves or no 1�ater meter readings. if available Las:pa;e o: o cc,-panc. OTHER: .De_cnbe Last date of occudanc. GENERAL INFORMATION PUMPING RECORDS and source of information. Q�tnnfped ��^+� 3 M� Da�ct. >ru ZNat?�c.'�cbu.� .oauy 4��91 , • System pumped as par, of inspection. (ves or no, If yes, volume pumped- gallons Reason for pumping TYPE OF SYSTEM Septic tank.ldistribution box'soil absorption system _ Single cesspool Ove-flow cesspool Prvq Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 4bSAA,\ Sewage odors detected when arriving at the site. (yes or no)�.. .. . . ..._ (r�vii�d 04/2S/9�) Da:• 5 of 10 SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORM ; PART C - SYSTEM INFORMATION (continued) Property.Add►ess: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade. - - - Material of construction: _cast iron _ 40 PVC _other (explain) = h well or suction Ii-. Distance from private water supply ---- --.- ' Diameter Comments: (condition of joints, venting. evidence of leakage, etc.) - - SEPTIC TANK:_ toocate on site plan Depth below grade-- Material of construLmon: _concrete _me-.a _Fioergiass _Polyethylene /ttheriexplain - - If tank is metal. Lis: age _ Is age cor.f;rmec b,. Ce^, ica:e o;Compuance (Yesno Dimensions Sludge depth Disidnce from top o: s!udge to bo:torn o*outie: tee or oa-'e Scum thickness Distance from top of scum to top of outlet tee or bade - Distance from boZorn o, scurn to bo-, om o; outlet tee or ba-,e how dimensions %ere determined Comments. trecommendation for pumping. rondition of inlet and outlet _s or baffles. depth of liquid level in relation to outlet invert. structural integrity, evidence of leakage, e:c.i GREASE TRAP: (locate on site plan; Depth below grade: Material of construction. _concrete —metal/lass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top/tion e or baffle. Distance from bottom of scum to outlet tee or baffie: Date of last pumping: Comments: (recommendation for pumping, c inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc (revised 04/25:91) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.A PART C SYSTEM INFORMATION (continued) Property Address: Owner. Date of Inspection: TIGHT OR HOLDING TANK: Tank must be pumped prior to, or at time, of inspections (locate on site plan, Depth below grade: Material of construction. _concrete _metal _Fibergiass _Polyethylene _other(explai Dimensions: Capacity: gallons Design flow galions'da, Alarm level Alarm in working order_Yes _ No Date of previous pu npmg Comments (condition of inlet tee. condition w a!arm and float switches. etc.) DISTRIBUTION BOX:_ (locate on site par, Depth of Iiou!d lever above oune: ime Comments tnote d leve! a-d distribut!or. is eoua'. evidence of solids car/over, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_, (locate on site plan. Pumps in working order: (Yes or No' Alarms in working order (Yes or No. Comments: (note condition of pump chamber, condition of umps and appurtenances, etc.) SUBSURFACE SEb%ACE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Prop" Addr-ss: 4)S Owner: News Date of Inspection: t( `1�157 SOIL ABSORPTION SYSTEM (SAS): (locate on site pian, if possible; exca%ation not required. but may be approximated by non-intrusive methods: if not determined to be present, explain: Type: _-_•�._._._....._.______. _ _.__..._�._.. __._.�..._.._.__.......:.___-� _ ..____ _. _..-. __ __.-...._. _ __ ... ._ ...... .._. .__.leaching pits, number_ ,:,........- _ _. ..leaching chambers, number: leaching galleries, number: leaching trenches, number,length: --- leaching fieids, number, dirne-isions. over'iow cesspool, number Alternative system Name of Technologv: Comments. - tnote condition of soil, signs of hydraulic failure, leve' of ponding, condition of vegetation, etc.) CESSPOOLS: (locate on site plar.Numbe, and config;ra:.or o1� 20u(,A Depth-top of liquid to inlet ur.er, \ - bow" Depth of solids lave- IL \-4`t Z_-".5 Depth of scum layer. *6 \-c7" IL? -O" Dimensions of cesspooi s I. Sx5 *2.-6A.-1 Materials of construcnor eCibacg cyr 4.kQeAc _ - indication or groundwate- MZ) inflow (cesspool must be pumpeC as par, of inspection) IJ Comments: (note condition of soil, signs of hydraulic failure, level of pondg, on 'on of vegetation, etc.) Zit 1� n 0 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.) (revatad 04125/91) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.. FORM PART C . - SYSTEM INFORMATION (continuedi Propert,, Address: lt5S QN%YMT6v.1 ArVj_ Owner: &ewS Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) i 41 �k'1 O � - A P � b O CLZ A - a�' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address ITSMkV5Ta^j Owner: apOM/S Date of Inspection: Depth to Groundwater=� Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, obsem-ation hole, basement sump etc.) Determine it from local conditions Cneck with loca! Board o, newtn Chec� FE.titiA maps Check p-imping record: . Check loca! excavators. Installers Use L SC: Da-a r• Desc',ibe in %.oJ, o%%n v.oros r,o•.% yo:: established the Cround- ater Elevation. (Must be completed: �� (l�a�� uX-�'z w � �(Tow• •.F C.r..a Qco ,4-T 3 lrav:sed 01:25'S', Page 10 of 10 aSS- 11� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , a 185 Marston Ave Property Address Gregory Bilezikian ,,� Owner Owner's Name information is ✓ ►-+ required for every Hyannisport —_ Ma 02601 1,,1,/1/16 page. City/Town State Zip Code Date of Inspection 6111 W Inspection results must be submitted on this form. Inspection forms may not be altered in any'N2 way. Please see completeness checklist at the end of the form. Important:When filling out forms A General-Information on the computer, use only the tab 1 Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain rea Company Name _------- -- --- 8 Johns path Company Address etun S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 _ S103522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection Was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation -the Loca pproving Authority lV6/16 -- ------- Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t51ns•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 17II// Commonwealth of Massachusetts W Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 185 Marston Ave _ Property Address — -- Gregory Bilezikian Owner Owner's Name — — ----- --------- -- --------- -- information is required for every Hyannisport_ — Ma 02601 _ 1 11 City/Town ----_- ---- pa 9e. y/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1,500 GI Septic tank as well as a concrete distribution box and seven flo diffusers. System is functioning properly. 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 f o 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•3/13 Title 5 Official Inspection Form: u .P Subsurface Sewage Disposal System Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is H annis ort _ __ _Ma 0_2601 1�/1/16 required for every Y_-� _ 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.): . El-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 :below (Explain ) ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .,M 9 185 Marston Ave Property Address ----------------- --—------- -— — _ Gregory Bilezikian Owner Owner's Name -- information is required for every Hyannisport _ —_ Ma 02601 1 1/16 page. City/Town State Zip Code Date of Inspect on B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a sept c 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 ❑ ® Stat'c liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is H annis ort Ma 02601 1 /1/16 required for every —y—__ _ 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: - ❑ y ® , _::,Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates.absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ . ❑ the system is within 200 feet of a tributary to a surface drinking water supply El❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5.Offcial Inspection Form:Subsurface Sewage Disposal,System•Page 5 of 17 Commonwealth. of Massachusetts ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 185 Marston Ave Property Address -- ----- -- Gregory Bilezikian Owner Owner's Name information is required for every Hyannisport Ma 02601 1V1/16 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 trey were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back u P 9 9 P? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ _ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual) 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage C isposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every Hyannisport Ma 02601 ' 11/1/16 page. City/Town State Zip Code Date of Inspection D. System Information Description: System contains a 1,500 GI Septic tank as well as a concrete distribution box and seven flo diffusers. System is functioning_properly. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 219 Gpd 9 ( Y 9 (gp ))� Detail Sump pump? ❑ Yes ❑ No y Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts • W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 185 Marston Ave Property Address GregoaBilezikian Owner Owner's Name _ — --- information is required for every Hyannisport Ma 02601 1IL1116 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: Pumped 2012 2016 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Site glass Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative:/Alternative technology. Attach a copy of the current operation and maintenarce contract(to be obtained from system owner) and a copy of latest inspection o-the I/A system by system operator under contract ❑ Tight tank Attach a copy of the DEP approval. ❑ Other(describe): !Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every Hyannisport Ma 02601 1X1116 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: 16 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.): Septic Tank (locate on site plan): Depth below grade: 1.5feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions Sludge depth: 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name -- information is required for every H annisport Ma 02601 111/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cont. Septic Tank p (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness Y Distance from 42".top of scum o top of outlet tee or baffle —. Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of leakin Tees and or baffles in place at time of inspection Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every Hyannisport Ma 02601 1A/1/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): t� a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 185 Marston Ave Property Address Gregory Bilezikian Owner Owners Name information is required for every Hyannlsport Ma 02601 1411/16 page. City[Town 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 Level and at normal level. Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No signs of carry over Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage DISDOS@l System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every H annis ort _Ma 02601 1 1/16 —�—� page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: leaching chambers, number: ® leaching galleries number: 7 ❑ 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.): Noponding no break out Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): "Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑. Yes ❑ No 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts. W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 185 Marston Ave Property Address Gregory Bilezikian Owner Owners Name -- information is required for every Hyannisport _ _ Ma 02601 _ 1;11/16 page. City/Town State Zip Code Date of Inspection- D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.).- No ponding no-break-out Privy (locate on site plan): Materials of construction: -- Dimensions _ Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ay 185 Marston Ave Property,Address Gregory Bilezikian Owner --- ------- -------- ---------- --- — Owner's Name information is H aY__nnts ort Ma 02601 1�/1/16 required for every __ _ �_ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Cornrmo.nwea.fth.of Massachusetts. • W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 185 Marston Ave Property Address ---- -- Gregory Bilezikian Owner Owner's Name — information is required for every Hyannisport Ma 02601 1V1/16 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ _Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft feet Please indicate all methods used to determine the high ground water elevation.- Obtained from system design plans on record If checked, date of design plan reviewed: 3/10/2000 Date ❑ Observed site(aoutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS.- database -explain: You must describe how you established the high ground water elevation: Test hole on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 910Z N/ii [=bas reddeul'dsp'�B dsI �urssass sn'a -e sure OUMO •MMM d ?SL i i 88Z=• � i PI�IHI d/ 19 � Q3 } / qu t NO.OF BEDROOMS BUILDER OR 0 PERMITDATEi: OD COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Fat Private Water Supply Welland Leaching Facility (If any:we is exist on site or within 200 feet of leaching facility) FeC1 Edge of Wetland and Leaching Facility(if any wetlands exist € within 300 feet of leaching facility) Feet t Furnished by 3 1 ' 3 i 3 3 4 • f/ i i. • 3 y�y V, 1 tip Y l 5 4 I 1� 4 IkI Z JO i 021?d P sp.feD 111ng-sy &cssassy Commonwealth of.Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System form - Not for Voluntary Assessments 185 Marston Ave Property Address Gregory Bilezikian Owner Owner's Name information is required for every [ annisport Ma 02601 121/16 page. CityFFown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r TOWN OF BARN 1 ° LOCATION wjesfaruk SEWAGE VILLAGE 1 aQ44 6, P* ''t ASSESSOR'S MAP& LO Y IfI '40V I JE: INSTALLER'S NAME&PHONE NO. - -Y.2 " '~ � 11 SEPTIC TANK CAPACITY f LEACHING FACILITY: (type ,... . : f (size) YYd 41 t NO.OF BEDROOMS E DER OR O Ie PERMITDATE: 06 COMPLIANCE DATE: p® Separation Distance Between the: Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r >' I � �. '� N� �� f No. �14 y THE COMMONWEALTIi,,O.F-MASSACHUSETTS FEE l01 BOARD OF HEALTH — OF — APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct V) Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components Location Owner's Name Map/Par el# Address e hone# faeK I r`s Name D igner's.Na e — Address � L Address Telephone# Teltplfbne# Type of Building: /7-5`J e;k 2 L t Size Sq.fee Dwelling—No.of Bedrooms Jr- G rbage Grin er ( ) Other—Type of Building No.of persons Sh wers ( ), Caf eria ( ) Other fixtures Design Flow(min.required) �Ogpd alculat design low gpd De 'gn flow provi ed SS gpd Plan: Date 3 '/ - oo Numb of shee Re ision Date -o Title S p Description of oil(s) 44-11 Soil Evaluator rm No. Name of oil E aluator Date of E alu on y c� DESCRIPTION REPAIRS OR ALTERA IONS The undersigned agre to ins II the a Item e de cribed I dividual Sewage Disposal System in accordance with p Isi f TITLE 5 and furthe I ce the y in peratio until a Certificate of Compliance has been issued by the B r of H c Signed Date FORM 1 - APPLICATION FOR SCP DEP APPROVED ORM V56 No. 6ff THE M EALTH OF MASSACHUSETTS FEE BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System The undersigned h r by certify that the Sew ge Disposal System;Constructed( ),Repaired(( Upgraded( ),Abandoned( ) by: Q - c: <c l at has been installed in accordance with the vrovisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to_a lic n No. dated J"2 2-0-r Approved Design Flow (gpd) Installers !Z4 LU Designer: Inspector Date The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 _ .,,>. No. OF/ THE COMMONWEAL'. I�O;F�ASSACHUSETTS Ie FEE /o/ -q BOARD OF F-IEALTH ' •, w� APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT ' I Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System j- � p y ❑Individual Components �f�35 le'_k457VAI A/�-,L imo Location Owner's Name j Zd—`(-1 /// j ap/Parcel# Address ephone# ! / I Ci7stil flc.) 1 1 's Name D iBers N n ' e �- ,//�y Address , Address - Telephone# o- Tel ph ne# ,Type of Building: L t Size Sq.fee Dwelling—No.of Bedrooms s, G rbage Grin er ( ) Other—Type of Building No.of persons Shy wers ( ), Caf teria ( ) 'Other fixtures Design;Flow(min.required)_ � --dgpd alculate design ow gpd De 'gn flow provi ed SS .s gpd Plan: Date 3 / - o� Number lOf she e Re ision Date TitleI i S i ,ramDescri )_�f� /Soil E No. Name of oilE aluator..-f" ✓�� Date of E alu on DESCREPAIRS OR ALTERATI NS '� The undersigned ogregto install the a fve des ribed l dividual Sewage Disposal System in accordance with fh prIV sio s of TITLE 5 and further agree nl3 ce the y tem in Aeration until a Certificate of Compliance has been iss by the B rd of H Ith Signed J Date i ns:ecttens .� 117 ' ki FORM .1 - APPLICATION FOR SCP DEP APPROVED RM 5/ 6 G t l j - i-yNo.}C�"'�O Y � , THE C �M�y�� .ALTH OF MASSACHUSETTS �`�� FEE-'/ d-.'��^-----�� BOARD.,`OF HEALTH -� CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System The undersigned her bycertifjtliat the Sewage DisposalSystem;Constructed( ),Repaired( Upgraded( ),Abandoned( ) by. a f , at has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to a lica 'on No. dated 2 2-rid Approved Design Flow gpd) Installer oi c— Designer: Inspector Date The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 ! ; No 'i -� T THE COMMONWEALTH OF MASSACHUSETTS FEE �( � - 1 l A� r;?BOARD OF HEALTH t - dd DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Constrlict ( ) Repair ( X Upgrade/ ) Abandon ( ) an individual sewage disposal system at / A ,A ,J#P T1411 6& i orb as described in the application for Disposal System Construction Permit No. dated Z ? -Q U r Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met. Date 3/ix1Z"_e Board of Health_�O `, ....� FORM 2 - DSCP DEP APPROVED FORM 5/96 , FORM 1255 (REV 5/96) H&W Homs&WARREN'" PUBLISHERS; BOSTON c � , tiI No. ;;Lg2nD U Fee 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYicatton for Migaar 6pgtem Congtructton 3permit Application for a Permit to Construct( )Repair( ' )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot N . j G 5�ty r'4 C) i/t Owner's Name,Address and TFFI.No. N m� rof Av f S �d�� (��#.x �h Assessor's Map/Parcel . Installer's ame,Address,,and Tel..,Ijo. r Designer's Name,Address and Tel.No. / Type of Building: Dwelling No.of Bedrooms .j Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow _5'3_0 gallons per day. Calculated daily flow gallons. 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) Date last inspected: Agreement: The undersigned agrees to ensure the con o and maintena e of the afore described on-site sewage disposal system in accordance with the provisio it e i on al o e,and not to place the system in operation until a Certifi- cate of Compliance has bee i sued o a Signe � c�a Date Application Approved by Date _ 1 4 Application Disapproved for the ollowtng reasons Permit No. ecr— Date Issued 2a 7 a -- Fee C7cD Entered in computer: THE COMMONWEALTHYOF MASSACHUSETTS V Yes r' PUBLIC HEALTH DIVISION -TOWN`OF BARNSTABLE., MASSACHUSETTS 01ppYication for Mie;paal *pztem Con.5truction Permit Application for a Permit to Construct )Repair Upgrade( )Abandon ❑Complete System ❑Individual Components PP ( P ( ) Pg ( ) P Y P Location Address or Lot N•. /8 j /Y9 4 e S o U Vkf Owner's Name,Address and T 1.No. / YA,v a r S CP�r� ((�a+ t C r i �__ A. Assessor's Map/Parcel ' Installer's INArne,Addresss `'d Tel °. ._---- Designer's Name,Address and Tel.No. f r11? �6 %i , �l�C_ �ouuN r,4 l�Ius�erS 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 Flows l/ i `` gallons per day. Calculated daily flow gallons. Plan Date i Number of sheets Revision Date Title f, Size of Septic Tank Type of S.A.S. R Description of Soil 1 `4 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: ; Agreement: The undersigned agrees to ensure the cons o and maintena e of the afore described on-site sewage disposal system in accordance with the provisio t e t ion al o e and not to place the system in operation until a Certifi- catep.of Compliance has bee I sued o d al Signe C29~� Date Application Approved by Date Application Disapproved for th ollowing reasons Permit No. e&n- L-1:2 Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance , THIS IS TO CERTIFY, that the O -site Sew ge Disposal System Constructed( )Repaired(YJ Upgraded( ) Abandoned( )by 1, v ff G `T at r c. { 1 has been constructed in accordance with thea s�e 5 ark the or Disposal System Co struction Permit Now.A Qr-;7_�,17 dated 3- 7 7 O 6 Installer o S f v 16A� 'Z—,cJ C Designer /Jv cu A2C r4� Yl e r ,uc�o e v C. The issuance o this permit h!&yMued as a guarantee that t st m will function as,designed. Date _ Inspector '? No. cno•- ? Fee—Eb 4, THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Misspogal 6pgtem Conotruction Permit Permission is hereby granted to Constru t )Re (�)Upgrade( )Ab on( ) r System located at o <v y e N ry I S u y and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. { Provided:Construction must be completed within three years of the date of this permit. Date: L4 _ I Y pproved by t, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 185 Marston Ave. Property Address ONEILL, J BRIAN & MIRIAM P Owner Owners Name information is required for every Hyannisport Ma 02647 11/23/2012 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones TitleV Septic Inspection �y Company Name 74 Beldan Ln. Company Address Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smonestitle5@gmail.com SI4522 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.T,e inspection was performed based on my training and experience in the proper function and maintenance=of on sewage disposal systems. I am a DEP approved system inspector pursuant 6o Section 1.5 340 of= Title 5(310 CMR 15.000).The system: :v ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority e.� 11/23/2012 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under " the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form: surface Sewage Disposal System•Page 1 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 't 185 Marston Ave. Property Address ONEILL, J BRIAN & MIRIAM P Owner Owner's Name information is H annis Ort required for every y p Ma 02647 11/23/2012 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 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 dwelling located at 185 Marston Ave Hyannisport is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 7 High Capacity Infiltrators surrounded by 4' crushed stone in a 11'x47.75'trench. The system was found to be in good working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �t 185 Marston Ave. Property Address ONEILL, J BRIAN & MIRIAM P owner Owner's Name information is required for every Hyannisport Ma 02647 11/23/2012 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M y` 185 Marston Ave. Property Address ONEILL, J BRIAN & MIRIAM P Owner Owner's Name information is required for every Hyannisport Ma 02647 11/23/2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, .safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 185 Marston Ave. Property Address ONEILL, J BRIAN &MIRIAM P Owner Owner's Name information is required for every H Yannis ort P Ma 02647 11/23/2012 page. CityrFown 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 colifonn 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 co of the analysis P 99 PY Y and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure E] ® criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection . Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11P10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 185 Marston Ave. Property Address ONEILL, J BRIAN & MIRIAM P Owner Owner's Name information is required for every Hyannisport Ma 02647 11/23/2012 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 555.74 gpd provided t5ins-11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .�` 185 Marston Ave. Property Address ONEILL, J BRIAN & MIRIAM P Owner Owner's Name information is required for every HY P annis ort Ma 02647 11/23/2012 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: seasonal use Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes .❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 185 Marston Ave. Property Address ONEILL, J BRIAN &MIRIAM P Owner Owner's Name information is required for every HY p annis ort Ma 02647 11/23/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 185 Marston Ave. Property Address ONEILL, J BRIAN & MIRIAM P Owner Owner's Name information is required for every Hy p annis ort Ma 02647 11/23/2012 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: system repaired 4/18/2000 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons 6" Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 185 Marston Ave. Property Address ONEILL, J BRIAN &MIRIAM P Owner Owner's Name information is required for every HY P annis ort Ma 02647 11/23/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 3" 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 10" How were dimensions determined? opened covers,took measurements 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 should be cleaned soon and again every 2-3 years for proper maintenance. Water level was good, tank was not leaking and was structurally sound. Outlet tee was intact. 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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 185 Marston Ave. Property Address ONEILL, J BRIAN & MIRIAM P Owner Owner's Name information is required for every Hy p annis ort Ma 02647 11/23/2012 - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: • Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 185 Marston Ave. Property Address ONEILL, J BRIAN &MIRIAM P Owner Owner's Name information is required for every Hyannisport Ma 02647 11/23/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 185 Marston Ave. Property Address ONEILL, J BRIAN & MIRIAM P Owner Owner's Name information is H annis ort Ma 02647 11/23/2012 required for every --� p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 7 High cap infiltrators ❑ 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.): s.a.s.was video inspected from the vent pipe and found to be dry with no sign of past hydraulic overloading. 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 r t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 185 Marston Ave. Property Address ONEILL, J BRIAN &MIRIAM P Owner Owner's Name information is H annis ort required for every Y P Ma 02647 11/23/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, 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.): I t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 185 Marston Ave. Property Address ONEILL, J BRIAN &MIRIAM P Owner Owner's Name information is required for every Hyannisport Ma 02647 11/23/2012 page. Cityrrown 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 L � f O � O � A-1 3`r ❑ 3 8-11 Ara yg t4 7 C- y 9 L15..s-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 1 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 185 Marston Ave. Property Address ONEILL, J BRIAN & MIRIAM P Owner Owners Name information is required for every Hyannisport Ma 02647 11/23/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 11 + 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: 3/10/2000 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: Design plan on file at Town of Barnstable health dept dated 3/10/2000 indicates that no groundwater was observed at 138"and system is designed to have a seperation of 5'+ between bottom of s.a.s. and adjusted high water elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I �\ Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 185 Marston Ave. Property Address ONEILL, J BRIAN & MIRIAM P Owner Owners Name information is required for every Hyannisport Ma 02647 11/23/2012 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 of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 T.O.F. VARIES • NOTE: EXISTING INVERTS OUT NOT FOUND THESE ARE PROPOSED MINIMAL INVERTS OUT LEGEND + VERIFY FEASIBILITY BEFORE CONSTRUCTION OF ANY PORTION OF THE SEPTIC SYSTEM. ACCESS COVER WITHIN 6" TO FIN, GRADE ACCESS COVER (WATERTIGHT) BRACE WITH P.T. 4"X4" .POST ��o WATER SHUT OFF VALVE WITHIN 6" TO FIN. GRADE 2" DOUBLE WASHED PEASTONE STAINLESS STEEL STRAP: ' TO BE LOCATED EL.37t EL.37t MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM .36 MAX AND SCREEN _�` EXISTING WATER LINE pp Box DB-5r� TO BE LOCATED z UE RIFY) C NLET W/ BAFFLE u ` = 5t 2 INLET PIPES, _ o -' (3 TOTAL) '-� TEE ON PUMP INLET RUN PIPE LEVEL O EXISTING WATER METER PIT A o PROPOSED 1,500 7FOR FIRST 2' 3' MAX. - n GALLON SEPTIC TEE CONNECT TO CHAMBER 1VITH v EL.3 * L.3 .05 IH-10 4' SCH40 PVC: AND V=NT �' ° � , s GAS SHUT OFF VALVE EL,33.0 SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED) O TO BE LOCATED HO z f TANK (H- 10 GAS �o� EL.32.8s NUMBER OF BEDROOMS: 5 EXISTING GA5 LINE PONs z Locus BAFFLE EL.33.03 1,9 VENT FLOW LI W2' SYS 1�+ V 1y 1 DESIGN FLOW: 5 BR x 110 G/D/BR 550 G/D �" APPROXIMATE LOCATION EL.32.50 16" USE A 550 G/P REQUIRED DESIGN FLOW Av 6" CRUSHED STONE OR MECHANICAL SEPTIC TANK: COMPACTION, (15.221 [2]) 4' c� �IDEs 10' @ IDES NOT tl SCALE -37 - EXISTING CONTOUR DEPTH OF FLOW = 4' 2' @ ENDS @ ENDS if EL.31.67 550 G/D (2) = 1 ,100 G/D +37.o EXISTING SPOT GRADE REQUIRED TEE SIZES: USE TWO PROPOSED 1 ,500 GALLON SEPTIC TANKS _ HYAN ORT INLET DEPTH = 10" MIN. BELOW FLOW LINE H-20 LEACHING: r �f t"} EXISTING SHRUBS OUTLET DEPTH = 14" MIN. BELOW THE FLOW LINE , 14" 14" �✓ & TREES (TYP,) g ` a SIDE AREA: 2 x 2 x (10.83'+47.75') = 234 SF LOW OVER HEAP WIRES (SLOPE VARIES) �oa�o 00o EL.30.50 � (� BUTTON AREA: 10.83' x 47.75' = 517 SF '�►u-` ELECTRIC CABLE T.V. ( 2. MIN. SLOPE) MIN. SLOPE) (� MIN. SLOPE) 3/4" To 1 1/2" DOUBLE WASHED STONE SIDES: 234 SF & PHONE LOCUS MAP FOUNDATION 37' SEPTIC TANK 2' D' BOX - 2' 7' LEA\CHiNG FACILITY + BOTTOM: 517 SF -�� PROPOSED CONTOUR SCALE 1" = 1000' (LONGEST LINE 37') (3 LINES TOTAL) TOTAL: 751 SF X36 PROPOSED SPOT GRADE 1 PROPOSED CAPACITY: 751 SF x 0.74 G/D/SF = 555 G/D O.K. UTILITY POLE ASSESSORS MAP 288, PARCEL 117 T.O.F. AT EL.36.58t }SACK YARD SEPTIC SYSTEM DESIGN DATA TH1 SOIL TEST HOLE ACCESS COVER WITHIN 6" TO FIN, GRADE 5' SEE TEST HOLE LOG(S) EL.35.8t REMOVE ANY CONTRA//NA7ED SOIL W;rHIS O LIGHT POST EL.35 MIN. 5' O-LEACH FAGYL/TY AND REPLACE 1%7tf ' MINIMUM .75' OF COVER OVER PRECAST LLERN MED/UA/ SAND �m w PROPOSED 1,500 EL.3 9 GALLON SEPTIC EL.3 .84 TANK (H- 10 GAS BOTTOM OF TH1 EL.25.5 ' BAFFLE SEE SOIL LOGS 6 CRUSHED STONE OR MECHANICAL DEPTH OF FLOW g 4' COMPACTION. (15.221 [2]) REQUIRED TEE SIZES: ELECTRICAL PERMIT REQUIRED INLET DEPTH 10" MIN. BELOW FLOW LINE OUTLET DEPTH = 14" MIN. BELOW THE FLOW LINE ALARM AND CONTROL PANEL IC BE INSTALLED INSIDE ACCESS COVER (WATERTIGHT) WITHIN 6" OF FIN. GRADE E>IiLDING. ALARM TO BE ON 8.4t% SLOPE SEPARATE CIRCUIT FROM PUMP EL 35 MIN (( 2 MIN. SLOPE MIN. SLOPE ( MIN. SLOPE) NOTES: \ ) ( ) (SLOPE DOWN FROM D-BOX TO PUMP CHAMBER) FOUNDATION 10' SEPTIC TANK 14' PUMP CHAMBER 101' D',BOX I I I I 1. THE LOCATION OF EXISTING UNDERGROUND UTILITIES SHOWN ON THIS PLAN IS INV. IN EL.32.5Q 1000 GAL. H--10 /T 2" PRESSURE PIPE TO D'BOX APPROXIMATE. PRIOR TO ANY EXCAVATION ON THIS SITE, THE EXCAVATING FRONT YARD 0.5% MIN. PIPE PITCH CONTRACTOR SHALL MAKE THE REQUIRED 72 HOUR NOTIFICATION TO DIG SAFE ALARM ON 791 GAL.+ ACK TO PIMP CHAMBER (1-888-344-7233) AND ANY OTHER UTILITIES WHICH MAY HAVE CABLE, PIPE OR FLOAT SWITCH RESERVE �INO LOW POINTS) EQUIPMENT IN THE CONSTRUCTION AREA FOR VERIFICATION OF LOCATIONS. SYSTEM PROFILE SETTINGS: PUMP ON WEEP HOLE 8 4 CHECK .VALVE 2. ALL SEPTIC WORK AND MATERIALS TO CONFORM TO 310 CMR 15.00 TITLE 5 NOT TO SCALE) 4" WORKING RANGE 4.. SUBMERSIBLE MODEL SRM4 MYERs AND BARNSTABLE HEALTH REGULATIONS. PUMP OFF 6" 4/10 HP PUMP SYSTEM 3. VERTICAL DATUM IS NGVD, ELEVATION ASSUMED FROM HYANNIS QUAD @ EL.30.. 00000r�o �, (OR EQUAL) 4. DESIGN LOADING FOR ALL. PRECAST UNITS ,00�oocc`a TO BE AASHTO-H 10. 6" CRUSHED STONE OR MECHANICAL 5. THIS PLAN IS FOR A PROPOSED SEWAGE DISPOSAL SYSTEM ONLY AND IS NOT TO BE USED FOR ANY, OTHER PURPOSE. COMPACTION. (15.221 [21) 6. PUMP DRY AND REMOVE OR FILL WITH SAND AN'Y-EXISTING LEACHING SYSTEM(S). 206 96' :� a - ACTORY WATERPROOFED PUMP �CHAMBER 7. ALL SEPTIC PIPING SCH-40-4" PVC UNLESS NOTED. _ 8. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT „ INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED .y PUMP C' HA.1 J -�• 9. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. (NO TO SCAL1�) 10. PIPE JOINTS TO BE MADE WATERTIGHT. 11. WATER TEST D-BOX FOR LEVELNESS. ,f39000-QW VENT r1.7 BELOCA7F0 kV 9VC 4&W *` a 12. * NOTE: EXISTING INVERTS OUT NOT FOUND THFSE APE PROPOSED MINIMAL INVERTS OUT, BY THE CON7RA07M A TIME cr INsrALLAnay. VERIFY FEASIBILITY BEFORE CONSTRUCTION G, ANY PORTION OF THE SEPTIC SYSTEM. PIPE FND. PROD 13. WATER SERVICES) NOT FOUND AT TIME OF PERC TEST CONTRACTOR TO LOCATE AND w, SIaL ABSORPnGYV SYSTEM 7 Hrc�l CAPACITY/NFKTRA72�?s N 20 MAINTAIN A 10 MINIMUM SEPARATION FROM THE PROPOSED SEPTIC SYSTEM AND 2�5E�7NEE�NGDS EIS THE WATER SERVICE (RELOCATE WATER OR ENCASE SEWER FOR 10' EITHER SIDE OF CROSSING IF NECESSARY). ZQ' AMO 1iF' OF S70VE BELOW. cLEMENrs 14. REFERENCE: "ADDITION FOUNDATION PLAN" ADDITIONS TO THE TUTTLE RESIDENCE, CONCRETE �p REMOV£ANYCONrAM/NA7ED S5VI IWIN/N RECEIVED 2/3/00 BY D,C.E., PLAN BY NORTHSIDE DESIGN ASSOCIATES BOUND FND. 2`� / i 5' CIF LEAa-1 FA=17Y AND REPLACE' W7H 3� GYE-AN/*ZZV MN SANG. 141 MAIN STREET, YARMOUTHPORT, MA 02675, (508) 362-2210, 362-9802. REWADE AS WOW N O re : IF S g'aT l L e 3\ PRO Te..-►1� w►L.A- I3e D- X B- �� 3 INLET W, BAME f S010OAL CW SEPnC rifAW H-10 �(N 10 LOADING NO PARKING OVER rANK) PIPE FND. 0y7RAC7t R 70 PRONDE fOUA49AnGW MAQ'NG - t IF NEEDED O 6"`,r, 230, hh S/ Ul 94 * NOTE EXISTING /NtzERTS OUT NOT FOUND, THESE ARE PROPOSED MINIMAL /NVEF'TS OUT, RESEP I u ' W tER/FY FEASIBILITY BEFORE CONSTRUCTION OF ANY PORTION OF THE SEr'77C SYSTEM. rEA DEPTH (in.) TH1 ELEVATION SOIL CLASS: I (SANDS, LOAMY SANDS) a` PERC RATE: < 2 MPI 5 MPI DESIGN � -'� CONCRETE Q" 37.0 ( ) BOUND FND. YR 4 4 PRESOAK: 0:20: GAL0: 0450 MIN.) ` SANDY LOAM NAIL IN 9" CEDAR CLEMENTs SN12 a -, " 3 N HMARK CONCRETE � q� ORi 1� 10 9", 0: 04: 05 E C BOUND FND. �f 3� 6 UNS IGTA LE 36.5 BOTTOM PERC: AT 60' EL.32.0 IEL.37.79 3 7 � LOAMY SAND 000 GAILAN PUMP 0YAMBER 1 N URA 8 NO WATER OBSERVED REGRADE As SJ�/DIfN �s f r l ?��• PosEo 24" C1 35.0 PATE: 12/20/00 SAVE"OR REZOCA7 LF ORNAMENTAL 7REES Q ENGINEER: MICHAEL S. FARIA, SE COV7RACTCR rO COCRD/NA7£ W7H ONVIR LIG T V' 1,500 GALLaN SEPTIC rANK COARSE SAND (DOWN CAPE ENGINEERING) o T 25 Y 7 � � /6 P p F ? . EXCAVATOR: BORTOLOTTI CONSTRUCTION wow' " WITNESS: DONNA MIORANDI r 3� 389� �•r � �o � Q� � �` UTILITY r 138 25.5 / CP 1Nv our POLE TEST HOLE LOG PRGV'GLSED /l l Y / NOT TO SCALE INV our t r� FLAG. � ?2g�, PATIO Q �9 ADO p�SE p 37.71 ,O r ^ N FF=EL.37.71 INV 0 T ,c L,33.9 w 4 29.62 CLEMENTsq�e.� #185 CONCRETE f 31NT EX15TiNG �� BOUND FND. "� r DWELLING `PC_ _� P TF=36.58t TITLE 5 SITE PLAN �- 36,58 a ---WATER OF LAND IN off. 508-362-4541 j'� ,` METER fax 508-362-9880 - �� o , ,� � HYANNISPORT , MA of M'sq� PREPARED FOR WILLIAM AND CHRISTINE TUTTLE dawn cape engineering, inc. SlTE ,LAN ARNE H. �Gs ��L Of Mqa� LOCATED AT 185 MARSTON AVENUE `\ 4 I CIVIL o� ARNE q�ti CIVIL ENGINEERS SCALE: 1 =20 N HYANNISPORT, MA O2G47- - ,r , �'� `\ No.3W92 U O,IALA T r� r LAND SURVEYORS EXISTING , ' ' ,� '�EcATE: 3 ►STE��G��`� 9p� No. �o� R� o " SCALE. 1 -20 REVISED: 3-10�00 CESSPOOLS fSs NAL BOARD OF HEALTH APPROXIMATE LOCATION(5) \ \ IVD Q REVISED: 3-10-00 MODIFIED TITLE 5 SYSTEM TO 5 BEDROOM DESIGN 939 main St. yarmouth, ma 02675 (SEE NOTE s> �'� �` � 20 0 20 40 60 Feet MA 99-3 9 APPROVED DATE BOUND F4 , DATE ARNE H. OJALA, P.E., P,L.5. ��_ BOUND 'JD. x