HomeMy WebLinkAbout0086 MIDWAY DRIVE - Health 86 Midway Drive '
Hyannis
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TOWN OF BARNSTABLE h
LOCATION $L IIidy y �riV� SEWAGE 4VI
VILLAGE ASSESSOR'S MAP&PARCEL 252--DS
INSTALLER'S NAME&PHONE NO. l,Julhft'.0 rVX(AVOO& i14 MUSe
SEPTIC TANK CAPACITY ISOO
LEACHING FACILITY:(type)PVJ, l (size)
NO.OF BEDROOMS 3 '
OWNER
PERMIT DATE: r$ COMPLIANCE DATE: 2
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 le ac ing facility Feet
FURNISHED BY
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No. 6 S Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppliration for Zisposal �&pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) ❑Complete System individual Components
Location Address or Lot No. � �1/� Owner' Name,Address,and Tel.No.
Assessor's Map/Parcel I Vim
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms �� Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.guirld) gpd Design flow provided gpd
Plan Date V
Number of sheets Revision Date
Title 1l
Size of Septic Tank Type of S.A.S. ?�
Description of Soil
�r lKU Al A C, Wa QN6.
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to-ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of thg Enviro Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Bo of e th.
Signed Date g 3/0-4
Application Approved by Date Z
Application Disapproved by Date
for the following reasons
Permit No. 20� } .) Date Issued 3 .?
-----------------------------------•----------------------------------------------------------------------- -
� ,� -.,.� .r,,.�. ;..� .:;^r.ry�rn� ,,.},,, wet '�.,��� S ++,,..r;..f^i#�, r-r'v+ 'R:z"`:.«� ..+a+' ';'•�,� 7r..*.K c r. „�,:.•.r",r.a.��r--<,,.�n T'`r �.,.s.",
y
No. 2 _ S 01 Fee
THE'COMMONWEALTH.OF MASSACHUSETTS Entered in computer:
e
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Zisp, stem Construction 30ermit
}
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) ❑Complete System XIndividual Components
Location Address or Lot No. („ Owner' Name,Address,and Tel.No.
VA(Ak
� 1�
Assessor's Map/Parcel R G,Am
t fA K '�
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
I •n�' �� bh � .�92�o�t� � • �n.�en. � 3I
Type of Building: j
Dwelling No.of Bedrooms t2 -Lot Size A D sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 1
Design Flow(min.requir d) SA gpd Design flow provided gpd
Plan Date ` Number of sheets Revision Date
Title i1C 1 h 1" ` i�� l. n
Size of Septic Tank Q Type of S.A.S. 1 Z C��t4t �`l ply[
Description'of SoilWd
-- °
Nature of Repairs or Alterations t(Answer when applicable)
Date last inspected: ;
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in,,
accordance with the provisions•of Title 5 of t Enviro rimprital Code and iiotftofplace the system in operationluntil.a Certificate of 4
».
' r•.� Compliance has been issued by thisJA
. f Ma
Compliance r� s.
d 4. Signed „ ,,.+1 R. t i ! ~Date 3/
Application Approved by F / Date / ?
Application Disapproved by i i r Date
for the following reasons • ,, a
Permit No: 2_0 . Date Issued 5/,3 J /
' 0
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
.k•.r Certificate of Compliance
THIS IS TO CERTIFY,that the'On- ite Sewage Disposal system Constructed( ) Repaired( ) Upgraded
Abando ed( )by �, - ._ C._. .. -r
at has been constructed in accordance
with the provisions of Title 5 anj the for Disposal System Construction Permit No.z"a 1/ I Srdated / a
Installer hm_r--)((Q V1� 10 .1 Designer
#bedrooms (� Approved design i w gpd
The issuance of this permit s 'll not He construed as a guarantee that the sy�esrf m will funetio, as d'-sign .
Date �L / Inspector
No. 2 / 5 Fee /00
THE COMMONWEALTH OF MASSACHUSETTS
S PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Bisposal *pstem Construction permit
Permission is hereby granted to Construct Repair Upgrade XAbandon
( )
System located at
K .I, Imo+ 1
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title.5 and the following local provisions or special conditions.
i
Provided:Construction must be completed within three years of the date of this permit.
,,Date i Approved by r, d
Town of Barnsta bl,
.egdutvey Services
Richard V.Scali,Interim Director
,
' -
MAM
Thomas McKean,Director
200.Maiu Street,Hyannis,MA 02601
Office- 508-8624644 Fax- 5O8n790-6304
Installer&Desityner Certification Form:
Date: ' sewage Permit## yo2l l
a ' �.�Assessor s M;zpTarcel `�� `�"�5'
Designer- ,: �e ~ n t x#cz ^��s $►t .Installer.
Address: J 2s I.clpzaAddress: �t '� "C,.ti v .r' ,✓ c
On 5'3-,)-r)g2 ! t�3 fin' �a J a (44_1 ued a lie a�it to install a
(date) (installer)
septic system at + t r ✓' �_` based on a design drawn by
G` Lis 1 k dated (3 t� )l"z l
(desi�per) ..
l certify that:the septic system referenced above was installed substantially according to:
the design, which tray include minor approved;changes:such as lateral relocation of the
distribution box anchor septic tank. Strip out (if required) wzts inspected and the sails
were found satisfactory.
I certify that the sei ne,system referenced above was installed,with major changes (i.e.>
greater than ltl' lateral relocation of the SAS or any vertical relocation of arty.component ;
.of the:septic system).but in accordance with State Se Local Rd uiations. Plan revision ter
certified as-built by designer to follow- Strip out(if required)ryas inspected and the soils
were;found.satisfactory.
I c rtify tl the system referenced about; was constructed in with the terms
of ie I a proval letters (if applicable) t
st I ignature): " tL
140.351
(Design S Signature) (Affix Designe �►�.. ere)
PLEASE RETURN TO BARNSTABLE PUBLIC 14EALTH I IVTS' NI.. RTIFWATE.
AT
4F COMPLIANCE 1VI"LL NOT--BE ISSUED UNTIL B:QTH TI S FORTH AND AS_
BUILT CARD ARE RECEIVED BY.'I IE HARNSTABIX r :
PUBLIC l�C"EAI.'1"H I�IVTSY€)i�
THANK YOU.
t�:Se em uesi zaci Unification"Form Rev 8-1.4-11doc
Engineers note-This certification is limited to,an as-built inspection of system t omponents as installed prior to baokiill.The
engineer did not Supervise construction of the system.The installer assumes responsibility for all materials,.worcmanship,bacKlilling
to specified grades vrith proper compaction and setting rises.?covera;as showai on the design plan.
41
No. ` / Fee `��AT,
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �r
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS f�
application for -Misposaf *pstem Construction Permit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ✓Individual Components
Location Address or Lot No. yAri;S Owner's Name,Add ss,and el No.
Assessor's Map/Parcel
Installer's Name Address,and Tel.No. CC O'i Designer's Name,Address,and Tel.No.
Type of Building: s
Dwelling No.of Bedrooms `J Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
U�\A O�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed �~ Date %*.,42 2-02-1
Application Approved by - Date
Application Disapproved by Date
for the following reasons
Permit No. ���� Date Issued 13 2
„`'ryt"�..1"1.r .r�r%L .�j-ry�`':�tl't,�,"n.Cv�«',.r7�/s. 'S =tiR, •.. � !r ,y„ tY—'4.r +...,�: ,w��hA,,,,k-y.,.-,`'t 7 . I.�.'. � .._'4:t.:�i..:-f -*.`ss'... °” s-"��*.`Z",
No. '�v`"`r I 1 r 5 *14' Fee
- THE COMMONWEALTH OF'MAS'SACHUSETTS A Enteredii omputer: Ak'
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEj MASSACHUSETTSes f n'.
2politation for Misposar *pstrm Construction 3pPrmit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System [v individual Components
Location Address or Lot No. � l t ?
\V� ��� '� \(-Xt1S'ts Owner's Name,Address,and Tel:No.
Assessor's Map/Parcel 5. q
Installer's Name Address,and Tel.No. <Jf3Z c� CADCo'j Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms ` f Lot Size sq.ft. Garbage Grinder( )
Other " Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures ,
Design Flow(min.required) Wh gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ( Type of S.A.S. '
Description of Soil { i
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected--,, If
Agreement: ' t
l The4mdersigned agrees"to ensure the construction and maintenance of the afore described on-site sewage''disposal system in k
,n
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
<
Signed "-' Date
i Application Approved.by / r <` Date 1,4/2/�_ /
a ti
Application Disapproved by Date /
for the'following reasons
Permit No Date Issued1-
:ZiZ
Tr;. .S ?.. .6�.m ..... a TP' e_'.'.••. _ _r_. ._.� __, T.
s_^« THE COMMONWEALTH OF MASSACHUSETTS
- BARNSTABLE,,MASSACHUSETTS
Certificate of COmptiance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed RepairedUpgraded
( )
Abandoned-( )by '�^ C�t)+t ••
at. v has been constructed in accordance i
k. with the provisions of Title 5 and the for Disposal System Construction Permit No. ,(}�, —I_) dated 5113 _/
Installer �Ep y'F(c Lt_ Designer
#bedrooms ►JIA- Approved design flow a ►V0�1 `gpd
The issuance of thistPevnit shall not be construed as a guarantee that the system wi f\ft nGtilor%as designed.
Insector (�
Date \,.. yo p��
s •No. -,�i� rl 7 _ ,. Fee �� r
THE COMMONWEALTH OF MASSACHUSETTS
►,'_% i� PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction permit
.; Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( )
System located at
r and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
k
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
K=Date � �_� Approved by
Town of Barnstable
oF1ne r
Regulatory Services
Richard V. Scali,Interim Director
* BA.RNSTABLE.
KASM
s6;g: Public Health.Division
�p
pTFDMAf Thomas McKean,Director
206 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 505-790-6304.
Installer&Designer Certification Form
Date: m Sewage Permit# Assessor's Map\.Parcel
i�c e c N c Cn+ems _
Designer: nee jYt� Installer: eu nvy`S �Xcq�lat �� "�'�
Address: )2 1nI Cf bs:s ,/c/ P� Address: '3'\
On Qu r r A v1 5 C'-,—`°--Jc-k-�"ti /sued a permit to install a
(date) ` (installer)
septic system.at 2te (A, A W ca.�4 P>✓' based on a design drawn by
(addr ss)
dated 3 13 t A 21
(designer)
.1 certify that the septic system referenced above was installed substantially according to
the design, which may include ininor approved changes such as lateral.relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above eras iri talled with major changes ( .e,
greater than 1.0' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in.accordance.,,vith State&Local Regulations. Plan revision.or
certified as-built by designer to follow. Strip.out(if required) was inspected and the soils
were found satisfactory.
I eJleign
e system. referenced above was constructed in with the terms
ofval.letters(if applicable) ,
o MEE
stture)
35109
(Designer's Signature) (Affix Designe .ere)
PLEASE RETURN TO BAR.NSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND As-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DI'\'ISION.
THANK YOU.
Q:`,Septic,;uesiancr Certification Font Rev S-14-13.doc
Engineers note:This certification is limited to an as-built inspection of system components as installed prior to backfill.The
engineer did not supervise construction of the system.The installer assumes responsibility for all materials,workmanship,.backfilling
to specified grades with proper compaction and setting risers?covers as shown on the design plan.
Town of Barnstable
Inspectional Services Department
' rsTae Public Health Division
y mass. $
031996 �m
E0 200 Main Street, Hyannis MA 02601
Office: 508-8624644
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4987 8128
March 10, 2021
KOZLOSKI, RUTH
PO BOX 113
OSTERVILLE, MA 02655
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 86 Midway Drive, Hyannis was inspected on 02/22/2021
by Brett Hickey, certified Title V Septic Inspector for the State of Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Discharge or ponding of effluent to the surface of the ground.
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\86 Midway Drive Hyannis.doc
Town of Barnstable
39BM
. 1 Inspectional Services Department
ATfD►u•�p Public Health Division
200 Main Street, Hyannis MA 02601
Oft ice: 508-862-4644
Thomas A.McKean,CHO
FAX: 508-790-6304
Feb 6, 2007
Rev. 4/26/19
- DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An "x" marked in the ❑ is the failure criteria and associated repair deadline
60 AY DEADLINE CRITERIA
ischarge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box is above the outlet invert due to an
overloaded or clogged SAS or cesspool
❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation
❑ A portion of the cesspool is located within a Zone I to a public well
❑ A portion of the cesspool is located within 50 feet of a private water supply well
with no acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessmentsr1
k�V��w
86 Midway Drive ,
Property Address
Ruth Kozloski
Owner Owner's Name
information is r .
required for every CentVIle Nannl*s Ma 02632 2-22-21 rr,
page. City/Town J 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. Inspector Information
on the computer,
use only the tab Brett Hickey
key to move your Name of Inspector
cursor-do not B&B Excavation Inc.
use the return Company Name
key.
374 Route 130
Company Address
Sandwich Ma 02653
IL Af City/Town State Zip Code
r 508-477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ® Fails
Brett Hickey 2-22-21
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 has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note:This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
0 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is Centerville Ma 02632• 2-22-21
required for every . -
page. City/Town State Zip Codd' ' ','Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) .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:
r
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
--_-- Title 5 Official Inspection Form
�- !} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t 86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of 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):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville . Ma 02632 2-22-21
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
�� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t
86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
® ❑ 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)]
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�. 86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents:
6
Does residence have a garbage grinder? ® Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage See below
9 ( Y 9 (gPd))�
Detail:
2020-73,623gallons 2019- 103,224gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- ji Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment: NA
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes,discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: last pumped 2-12-21
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components,date installed (if known)and source of information:
1994 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: town water
feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
--- , Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y3' 86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade 1: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gallon
Sludge depth: Tank full over inlet and outlet
Distance from top of sludge to bottom of outlet tee or baffle na
Scum thickness na
Distance from top of scum to top of outlet tee or baffle na
Distance from bottom of scum to bottom of outlet tee or baffle na
How were dimensions determined? viewed
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was full over the inlet and outlet due to a failed SAS. System backed up onto ground.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a. 86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: NA
feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ®other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
'liquid levels as related to outlet invert,evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
NA
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
15lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
lip Title 5 Official Inspection Form
r- 11- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm In working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches,etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert over
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.):
The d-box was overfull due to failed SAS.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
r
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t
86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
NA
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 6'x6'
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t51nsp.dDc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation,etc.):
The SAS was in hydraulic failure when viewed. System backed up onto ground.
12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration NA
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
86 Midway Drive
Property Address
Ruth Kozloski
Owner Owners Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or 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
T0WW'0P BARNSTAUX's
LC>iG1.TiC7dY �.. .ate ra�,K.
VILLAGE SE WAC E
drvsTwcd:a�a�s sr '"� �sso�Fe A¢Ap at tcxr mas-�._a, , .
SUPTd+C rA141kCAPAC:f'L, �PV,SC" f�q� 1
LSAck[ING F!►CIL dTl's�
SUI LDENt Q {Yt.I> QPRIVA T$ RtY$LL l? BLIC RrAT} E
DATE PERMIT ISSUED,
b ►T 8
CCaMPC.tANCdi ISSiJB$?• l
VA;RIANCB GR.SdVTEZ>: Yes ••-
,yy
1
*6iip'idoc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�� 86 Midway Drive
Property Address
Ruth Kozloski
Owner Owner's Name
information is required for every Centerville Ma 02632 2-22-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: Not determined
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators,installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Ground water not determined as system is in failure.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachu
setts
r, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Midway Drive
Property Address
Ruth Kozloski
Owner Owners Name -
information is Centerville Ma 02632 2-22-21
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed.& Dated and 1, 2,3, or 4 checked
® C. Inspection Summary:
1,2, 3,or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
w HOBBSBWARREN'm THE COMMONWEALTH OF MASSACHUSETTS
FORM 30 �I
� BOARD OF HEALTH
CITY/TOW N
o DEPARTMENT
ADDRESS
TELEPHONE
F/ b l 7d
Occupant` .y �� ws
Floor Apartment No. _ - _ _ _ No.of Occupants_ l _
No.of Habitable Rooms_ —_..� No.Sleeping Rooms
No.dwelling or rooming units No.Stories
Name and address of owner����'r'�'__ �„�'�'����� � .� r/ 4:1174,e4 _
J ==
l--ra 'i` 1, ��t' e— , fib" z/ r,4.. ��! �':� �s � f xl Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls: _.��,� � '�'"� �. ,��-��, .�• �,✓,r'.�'.f.�.�°' :+��°r�,�K.G�,-�
Foundatior
Chimney':
BASEMENT Gen.Sanitation:79F-r
Dam ness :f ,,«
Stairs: , .z'-r `r, :t`s r .�,
Li htin : A 4;1G 7°�a: �.� r ter� �✓� �d�
STRUCTURE INT. Hall,Stairway: �, �,. . s r:�t , tag `,.;I' - r �:+•'x%'
0bst'n.:,d 14 4 ./f &;.fry G1 y!/ ' f/�4; I
Hall, Floor, -7,--.#:'5c"I' A' ;60-7
Hall Li htin -.)5 3` 4,-/t+eF>,' � S:a , �. :�-� •t.
Hall Windows:? r
HEATING Chimne s x�A,,5 a
Central ❑.Y ❑ N Equip. Re air/,,//�•r r � � 7 , r� x.. - . r . € �v`< / P
TYPE: -Stacks, Flues,Vents: - `
PLUMBING: Supply Line:4611`1'i -1i 6"R'., .ri' a 411' 1 da ;" ' A110 F3
❑ MS ❑ ST ❑ P Waste Line:�t A T s.9 '71, 4 4,•
H.W.Tanks Safety and Vent(s),r✓'ta~'' 1 .s x r r�
EL-ECTRtGAL Panels, Meters,Cir':7" 4;� f" 4`f rr-•7- 'e
❑ 110 ❑ 220 Fusing, Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom(1)
Bedroom 2
Bedroom 3
Bedroom 4
Hbt Water Facil. Sup.Ten.,Gas,Oil, Elect..-
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub: ,
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n: If
General Building Posted o ,2442 ixkh.,r Slf x -1Y4 Fmk
Lecks,o,n,Doors: 14 IV,4 _t�jg:s h 1&0.1 UAr Flo v-49 l'
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITJON WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AO)THORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJURY."
INSPECTOR.-- x�'�"9f' � "�� TITLE q ✓rP
AvM-
DATE f < ' I�''" Lt TIME__ .✓` P.M.
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitfing, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 86 MIDWAYDRIVE
Property Address
LINDA SETHARES
Owner Owner's Name
information is required for HYANNIS MA 02601 4/9/2007
every page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
�a 9�
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your ADAM R. RIKER
cursor-do not Name of Inspector
use the return
key. RIKER LANDSCAPE CONSTRUCTION
Company Name
PO BOX 726
Company Address
SOUTH YARMOUTH MA 02664
City/Town State Zip Code
5087766460
Telephone Number License Number
B. Certification F
I certify that I have personally inspected the sewage disposal system at this address�and that-the T
information reported below is true, accurate and complete as of the time of the inspection. TWinspection
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 m
❑ Needs Further Evaluation b the Local Approving Authority
y pp 9
S .7 oG.
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.
r
86 MIDWAY INSPECTION•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 86 MIDWAYDRIVE
Property Address
LINDA SETHARES
Owner Owners Name
information is required for HYANNIS MA 02601 4/9/2007
every page. Citylrown 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:
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.
Answer yes, no or not determined (Y, N, ND) in the ❑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.
ND Explain:
❑ 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
❑ obstruction is removed
86 MIDWAY INSPECTION•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
• T
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
86 MIDWAYDRIVE
Property Address
LINDA SETHARES
Owner Owners Name
information is required for HYANNIS MA 02601 4/9/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ 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
❑ obstruction is removed
ND Explain:
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
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.
I ❑ 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.
86 MIDWAY INSPECTION•08/06 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 86 MIDWAYDRIVE
Property Address
LINDA SETHARES
Owner Owner's Name
information is required for HYANNIS MA 02601 4/9/2007
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
❑ ® 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.
86 MIDWAY INSPECTION•08f06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
vm
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
86 MIDWAYDRIVE
Property Address
LINDA SETHARES
Owner Owner's Name
information is required for HYANNIS MA 02601 4/9/2007
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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 16,000 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.
86 MIDWAY INSPECTION-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM ` 86 MIDWAYDRIVE
Property Address
LINDA SETHARES
Owner Owner's Name
information is required for HYANNIS MA 02601 4/9/2007
every 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)]
86 MIDWAY INSPECTION•08106 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
86 MIDWAYDRIVE
Property Address
LINDA SETHARES
Owner Owner's Name
information is required for HYANNIS MA 02601 4/9/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 3
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 ears usage average 125gpd
9 ( Y g (gpd))�
Sump pump? ® Yes ® No
Last date of occupancy: CURRENT
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:
Last date of occupancy/use: Date
Other(describe):
86 MIDWAY INSPECTION•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 86 MIDWAYDRIVE
Property Address
LINDA SETHARES
Owner Owners Name
information is required for HYANNIS MA 02601 4/9/2007
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: BARNSTABLE WATER POLLUTION DEPT.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: REQUESTED 1000 gal.
gallons
How was quantity pumped determined? no
Reason for pumping:
MAINTANCE
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)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
INSTALLATION IN 1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
86 MIDWAY INSPECTION•011106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 MIDWAYDRIVE
Property Address
LINDA SETHARES
Owner Owner's Name
information is required for HYANNIS MA 02601 4/9/2007
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 20"feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 20
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
GOOD CONDITION NO LEAKS
Septic Tank(locate on site plan):
Depth below grade: 1
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: 4'10"wide x 8'6" long x 68" high
6�
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 3 feet
Scum thickness
8"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? cloth/stick
86 MIDWAY INSPECTION-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 86 MIDWAYDRIVE
Property Address
LINDA,SETHARES
Owner Owners Name
information is required for HYANNIS MA 02601 4/9/2007
every 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.):
system had no signs of previous overflow
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
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):
f 86 MIDWAY INSPECTION•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
86 MIDWAYDRIVE
Property Address
LINDA SETHARES
Owner Owners Name
information is required for HYANNIS MA 02601 4/9/2007
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
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
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert >111
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.):
RISER AND COVER REPLACED
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
86 MIDWAY INSPECTION•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11.of 15
Commonwealth of Massachusetts
.19 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
86 MIDWAYDRIVE -
Property Address
LINDA SETHARES
Owner Owner's Name
information is required for HYANNIS MA 02601 4/9/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology.
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
6'X10' PRECAST LEACH PIT
86 MIDWAY INSPECTION•08/05 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�< 86 MIDWAYDRIVE
Property Address
LINDA SETHARES
Owner Owner's Name
information is required for HYANNIS MA 02601 4/9/2007
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
86 MIDWAY INSPECTION-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
86 MIDWAYDRIVE
Property Address
LINDA SETHARES
Owner Owner's Name
information is required for HYANNIS MA 02601 4/9/2007
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
fr n4- 0
��r n
3
86 MIDWAY INSPECTION-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
• Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M rt 86 MIDWAYDRIVE
Property Address
LINDA SETHARES
Owner Owners Name
information is required for HYANNIS MA 02601 4/9/2007
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
Z Shallow wells
Estimated depth to ground water: >15'
feet
Please indicate all methods used to determine the high ground water elevation:
EJ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
® Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
attached copy of current readings
You must describe how you established the high ground water elevation:
used Cape Cod Commision well#sdw-252 readings and adjustment
augured 2-1/2"x 15'test hole on property at same grade elevation as s.a.s. finding no water
86 MIDWAY INSPECTION•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 15
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: %Uvp V ��►''� T'�Vun/�l5 Lot No.
Owner: L d-1 4 Address:
Contractor: Address:
Notes:
�I STEP 1 Measure depth to water table
to nearest-1/10 ft. .............................................................................. .Date
Y
II month/day/Year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OA Appropriate index well.............................................. $�1
i C '
OWater-level range.zone .....................................................
STEP 3 Using monthly report"Current
Water Resources Conditions"
determine current depth to
I� water level for-index well O ��'
mo th/year
STEP 4 Using Table of Water-level Adjustments
for index well_(STEP 2A), current depth
} to water level for index well (STEP 3),
and water-level zone (STEP 26)
determine water-level adjustment ....................................................................................:. off.
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1) .............................................................................................................
Figure 13.—Reproducble computation form.
15
1-
Town of Barnstable
Regulatory Services
do Thomas F. Geiler,Director
s
CAB . * Public Health Division
9�A S.
1639. ��� �
Thomas McKean Director
tED MA'S A
367 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
(Owner)Ms. Linda Sethares (Tenant)Mike and Dewana Durant
96 High Bank Rd. 86 Midway Drive
South Yarmouth, MA 02664 Centerville, MA 02632
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY
CODE 11. MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51
The property owned by you located at 86 Midwayy-Drive;Centervil-le MA 02632 was inspected
on December 10, 2001 by Edward Barry, Health Inspector for the Town of Barnstable,because
of a complaint. The following Violations of 105 CMR 410.00, State Sanitary Code II,
Minimum Standards of Fitness for Human Habitation were observed:
410-351A The tenant claims water floods the basement when taking a shower, and the bathroom
drain leaks. No visible trap for the bathroom sink. Tub fixtures are not secure. The toilet
continues to run after flushing.
410-500 The bathroom tile around the tub is partially dislodged, black and some of the tiles are
missing. The floor in the kitchen and the bathroom are spongy to walk on. The floor covering in
the kitchen is deteriated, and the sub flooring in basement is water stained. There is evidence of
mold in basement and in the two bedrooms.
410—481 No 20 sq. inch sign provided bearing the name, address and the telephone number of
the owner.
You are directed to correct the violations ABOVE within FOURTEEN (14) days of receipt
of this notice.
You may request a hearing if written petition requesting it is received by the Board of Health
With seven(7) days after the date order is received. However, these violations must be corrected
regardless of any request for a hearing.
Please be advised that failure to comply with an order could results in a fine of not more than
$500 each separate day's failure to comply with an order shall constitute a separate violation.
You are also subject to non-criminal citations of$40.00 for the first violation and$15.00
For each additional violation. Tickets will be issued daily until the violations are corrected.
�F
Regulatory Services
Thomas F. Geiler,Director
�t T°wti Public Health Division
o�
iAMffABM * Thomas McKean, Director
gib ': `0�' 367 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
(Owner)Ms. Linda Sethares (Tenant)Mike and Dewana Durant
96 High Bank Rd. 86 Midway Drive
South Yarmouth,MA 02664 Centerville,MA 02632
1
NOTICE OF CORRECTIONS
The property owned by you located at 86 Midway Drive, Centerville MA 02632 was re-inspected
on December 28, 2001 by Edward Barry,Health Inspector for the Town of Barnstable. The
following violations of 105 CMR 410.00, State Sanitary Code II,Minimum Standards of
Fitness for Human Habitation were corrected.
Violations Corrected:
The bathroom drain has been fixed, the trap is in-place in the bathroom sink,tub fixtures have
been secured, The toilet flush has been fixed.
There is a 20 sq. inch sign bearing the name, address and telephone number of the owner. This
sign is hanging on the back of the front door.
mas A. McKean
Director of Public Health
Q/health/wpfiles/order
a .R
Town of Barnstable �
oEtMME r Regulatory Services
c Thomas F. Geiler,Director
s
BARNSTABLE Public Health Division
9`bA 1 . ��� Thomas McKean,
Director
rE0 MA'S A
367 Main Street,Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
(Owner)Ms. Linda Sethares (Tenant)Mike and Dewana Durant
96 High Bank Rd. 86 Midway Drive
South Yarmouth,MA 02664 Centerville, MA 02632
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY
CODE 11. MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE, ARTICLE 51
The property owned by you located at 86 Midway Drive, Centerville MA 02632 was inspected
on December 10, 2001 by Edward Barry, Health Inspector for the Town of Barnstable,because
of a complaint. The following Violations of 105 CMR 410.00, State Sanitary Code II,
Minimum Standards of Fitness for Human Habitation were observed:
410-351A The tenant claims water floods the basement when taking a shower, and the bathroom
drain leaks. No visible trap for the bathroom sink. Tub fixtures are not secure. The toilet
continues to run after flushing.
410-500 The bathroom tile around the tub is partially dislodged, black and some of the tiles are
missing. The floor in the kitchen and the bathroom are spongy to walk on. The floor covering in
the kitchen is deteriated, and the sub flooring in basement is water stained. There is evidence of
mold in basement and in the two bedrooms.
410—481 No 20 sq. inch sign provided bearing the name, address and the telephone number of
the owner.
You are directed to correct the violations ABOVE within FOURTEEN (14) days of receipt
of this notice.
You may request a hearing if written petition requesting it is received by the Board of Health
With seven(7) days after the date order is received. However, these violations must be corrected
regardless of any request for a hearing.
Please be advised that failure to comply with an order could results in a fine of not more than
$500 each separate day's failure to comply with an order shall constitute a separate violation.
You are also subject to non-criminal citations of$40.00 for the first violation and$15.00
For each additional violation. Tickets will be issued daily until the violations are corrected.
PER ORDER OF THE BOARD OF HEALTH
Thamas A. McKean
Dir for of Public Health
Q/health/wpfiles/order
Regulatory Services
Thomas F. Geiler,Director
CF SNE �
do Public Health Division
BARNSTABLY. ; Thomas McKean,Director
9eb 16 9. ,0�' 367 Main Street, Hyannis,MA 02601
QED MA'S A
Office: 508-862-4644 Fax: 508-790-6304
(Owner)Ms. Linda Sethares (Tenant)Mike and Dewana Durant
96 High Bank Rd. 86 Midway Drive
South Yarmouth,MA 02664 Centerville,MA 02632
NOTICE OF CORRECTIONS
The property owned by you located at 86 Midway Drive, Centerville MA 02632 was re-inspected
on December 28, 2001 by Edward Barry,Health Inspector for the Town of Barnstable. The
following violations of 105 CMR 410.00, State Sanitary Code II,Minimum Standards of
Fitness for Human Habitation were corrected.
Violations Corrected:
The bathroom drain has been fixed, the trap is in-place in the bathroom sink, tub fixtures have
been secured, The toilet flush has been fixed. ,
There is a 20 sq. inch sign bearing the name, address and telephone number of the owner. This
sign is hanging on the back of the front door.
4N
masA. McKean
Director of Public Health
Q/health/wpfiles/order
pr TOWN OF BARNSTABLE '
LOCATION 11" IbWA-q 441 ttC SEWAGE # AM 9'9�196
VILLAGE SESSOR'S MAP & LOT o�,C4-0,S5
s
INSTALLER'S NAME &,.PHONE NO. Vr, tre---zw'tl7
SEPTIC TANK CAPACITY.
LEACHING FACILITY:(type) _ C/j (size) f0
NO. OF BEDROOMS PRIVATE WELL O UBLIC WATER
. BUILDER O OWNER /O %2�i��-�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No,
v
No...l..:"(f1 FEs...��J...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for-,Diti-pnittl Works Towitrurtinn lirrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( Wan Individual Sewage 'Disposal
System at:
d Location-Address or Lot No.
12-41A-L�"I c cs /`��r�.. �� -----• =---------�r�/1s-------------------------------__..
Address
W ...............................................lf 0 I�3.5 J7L�IC.�T In 7 J—inl���X
caner
Installer Address
dType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms................�-•-_--.-..-_._.-.....Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ............................ No. of persons--------------------------- Showers ( ) — Cafeteria ( )
44 Other fixtures .-_------------ ---_.--.._.. . -
W Design Flow.............. ._.-._.__._...gallons per person per day. Total daily flow---------s; .....................gallons.
WSeptic Tank—Liquid capacity------------gallons' Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width..-........_-_...... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----------/........ Diameter......./Q..... Depth below inlet................ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
aTest Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water-.------..--__._-_.-_.-.
W --------------------------------------------------------------------------------'-------------_-• -----------------------------------------•-•.........
...-.
0 Description of Soil.................................................---"'.._..-""•-----•---'-'-•---------------.....'---------------""-•-••'•'•---•--------•------'----'--'-'--'-''...
x
----------------------
U Nature of Repairs or Alterations—Answer when applicable......�/..N -..._--�-_...--- U;�.!
a.�lL L)�.f.' �f�+L �-1c-(e (_ ----- --=`f---- 1........... .............................
/------- .1 - --'r
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Compliance as een -ss ed b e board of health.
Signed -------- ----- --------- -------,-.------.....------------------------------------------------------- -----�.--���......
te
Application Approved By -------------- -- ----..v-----..------- ----------------------- -/I--�-16-- t�
Application Disapproved for the ollowing reasonf. ................._......._. . ............ .... ... . .................__..........-------------
.......... ...................:.... �.................. . .. ................... . -- ................................-....... ------- �... ....
y► ) �+, -- Date
Permit No. .... ��- ' - Issued /�L:�.. ..77..1...��..... - ..............
Date
_ r -
No...!i-- FI;a...a....-.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for DiuVo!ial Vork.6 Cnuntrnr#iun Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( Wan Individual Sewage Disposal
-''System at:
tJ C cs N c+C- I I L
..............••------•-----___.•..•.-----••---.....-----....------------------•-•-............... ...-•-••--•-••-----••--•-••-•--•--•---••-----•----•---•-•--•-----••-•-•-••-•---.......-••-....----
3 Location-Address or Lot No.
C d 2 r4-L_77 5 SP - t� t�11,5
------------------�- -••---------------••---•---------..--
c Owner �_ Address
W >.�/t-=�I✓... 1. C`_a rJs��'Wc.�l'i' VIQ G ��I.a K . �l , .4 t LC5
Installer Address
UType of Building � Size Lot............................S q. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
QI Other fixtures _________________________________
W Design Flow................ _-gallons per person per day. Total daily flow-----------3!-....................gallons.
WSeptic Tank—Liquid capacitv.........._gallons Length................ Width---------------- Diameter---.------------ Depth................
x Disposal Trench—No. .................... Width--------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........ ----- Diameter-------- U....-_ Depth below inlet-------�_........ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1-4 Percolation Test Results Performed by.......-.................................................................. Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water......................
fX4 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
P4 ----••-•---•--------------•---------•---•-----•----------•-•-----•-••-•---••••......-•-•••......----........................................................ ;
0 Description of Soil........................................................................................................................................................................
x
V ---------•-•--•-------------------------------------------------------------------------------------------------------------------------•-------------------------------------------•-•-•••----•------•-
W
U Nature of Repairs or Alterations—Answer when applicable..-_.-!. _� `!_ ...__. . .......� 0y.!.��.__..SeaT-I�-
.....
/---------.C.: --------------------- .................................................---...------------.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of.TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance, `as been 'ss ed bb the board of health.
Signed ..... - ! -- ` .:.G ...... ............... ......
Dare
Application Approved By .............C
j
......... .. / �--------------- ----------------------------Application Disapproved for the followan reasons- ------------------------- _
............................. -.................................� --------------------.......---- -----......---.....--------------------------......... 1! '
Daie
Permit No. ----- L_-------=16 6----------------------- -- Issued - -------------------------
Daze
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifi ate of (111ontylianre
THIS IS TO CERTIEK That the Individual Sewage Disposal System constructed ( ) or Repaired (?` )
by ------------------------__----------- t r CU.(&TI-- ....._ .:G.!�!S ^J. `1:%dh j---.......-----...........------...........--------------------------------------
ms�auer
at _...... .:.... 15 (a..... �/1�1 L O .i4- -------- D 9—AV,- t
- t -----------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ...-..... .....&64� -------------- dated .._.AL..-.�...T.._.L1_......-..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR.I�E AS A GUARANTEE`TH �T THE
SYSTEM WILL FUNCTION SAT I FACT Y.
DATE.... /........�.... ` ... _ Insp ctor -------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No...Ct� FEE...........'
�ts ,au�t1rk Tun#riun Permit
M Permission is hereby granted------------_------
.....................................
to Construct ( ) or Repair n-Individual Sewage Disposal System
at No.•--••••••-•--•--••-•---•------------•--•••.-----•-K 4---•--- 1'k1 ()0 '"1 /)raN�.�•-I......C�
Street
as shown on the application for Disposal Works Construction Permit No..... _.___//�6 Dated------- �...7�v...........
o V e�oard of Health
DATE---------------:----- K----/--1------------•-----------------------
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
TOWN OF LOCATION BARNSTABLE
ttc
VILLAGE SEWAGE # y"
ASSESSOR'S MAP G LOT
INSTALLER'S NAME ,6,PHONE NO.
-f—
SEPTIC TANK CAPACIT'y
LEACHING FACILITY:(type) / 177
NO. OF BEDROOMS / _(size)
BUILDER O BL �p fQ
��PRIVATE WELL OR �
�`ICATER
W _
OWNER o
DATE p -tt�-�' s
ERMIT ISSUED:
If 9
DATE COMPLIANCE ISSUE
.VARIANCE GRANTED: yes v
No I
I
y7
i
IS o2� i
I
. aZi 3s1 '
r
i
w
—— 98 —— EXISTING CONTOUR
x 100.98 EXISTING SPOT GRADE 1.`ti ''C,c•_ G. ,\r` ` �7.,`i" r�o
W PROPOSED WATER SVC.
OVERHEAD WIRES
„ TEST PIT �1`�''
=1 J
BENCHMARK ;!\ \ �> fimQ; .��o �' tom/ rr.: 'i '!
LEGEND �.: :' ,« ,, ,. `.,._..z.. :i f_=., a
C h1c. t ✓ s �y0 h ..y t4;�
A VEND , OZZ,
f
100,53 Cente
100.36 : --.-'
; rville M%1
} 0263
cl
�Oli�o ) ,) /.�^' '-•-'._i, `"-,-Mtilwey'Qi"_''.-.--.-'�J�' .�.W d `+,�5..• �,"
48.26' c 100,22�
99.85
LOCUS MAP
J W'�
LOT 23� 00.35
I .1
7,610±S.F. 0 PROPOSED S.A.S. GENERAL NOTES:
� $ .2-500 GAL CHAMBERS 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
X 100.83 �1`L 8 ' �" {SURROUNDED W/4' STONE BOARD OF HEALTH AND THE DESIGN ENGINEER.
W Z �•-1 O •: �� q 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
,... 1
1 DMH OF THE STATE ENVIRONMENTAL CODE TITLE V AND ANY APPLICABLE
�.. 100.49i
100,66 LOCAL RULES AND REGULATIONS EXCEPT AS RE REQUESTED BELOW:
p .. �c i O 99.08
E Q
!n O 0 L. a -310 CMR 15.405(1)(b): LOCAL UPGRADE APPROVAL
00 0 10 ,65 TP�1:. '� j 99;00 1) A 10' variance, S.A.S. to cellar wall, for a 10' setback.
O 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
O '— O TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
CATCH
DESIGN ENGINEER,
Z TP-2 :'1 1 2 l ASIN 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
BENCHMARK-1 1 cso�ld>
100,68 •''•F i � FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
BULKHEAD CORNER BN EXISTING II CON y✓A K � ENGINEER BEFORE CONSTRUCTION CONTINUES.
EL.=101.20 TBM1 i. 98.96 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM.
T.
' 100,55 101.20 HOUSE(#S6) TBMz '�' ' BENCHMARK-1
O.F.=101.2.t 101.40 3 BULKHEAD 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
EAD CORNER
Z..'.: ULKH 1.40
0 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
�:.�f HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
110 .55 X 1
EXISTING SEPTIC TANK x 2� trj d :•�... 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
(TO REMAIN) 100.57 100,48 /� co .,`; 8. THERE ARE NO WELLS WITHIN 100' OF THE PROPOSED S.A.S.
TOP OF TANK, EL.=99.77t i M"9 ,•Q,B
�.� �.. Q) � 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
INV.(OUT)=98.44.t AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE
100.111 Q. DIRECTED BY THE APPROVING AUTHORITIES.
10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
GRAVEL CONSTRUCTION.
x 100.36 ��� r.:> .�: : m s�
DRIVEWAY; . ;;"q, :..::.. 1 1. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
fence 100,10 k� : :. : •. :9+ <. ' . : a
99 8,�.>._:•. .>:` aj 1 IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
X 7�'31 99.72 REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3).
N 81*53'10- 9&85 j 12. AREAS
INSPECTED BY GSIGNIPEOUT UNSUITABLEOFR BACK MATERIALS SHALL BE
99,68
OF � PARCEL ID: 252-059
���� MAss9c EXISTING LEACH PIT 98,82
o� PETER T. y✓' TO BE PUMPED, FILLED PROPOSED .SEPTIC SYSTEM UPGRADE PLAN
M CIVIL E W/SAND & ABANDONED 86 MIDWAY DRIVE, HYANNIS, MA
No. 35109 Prepared for: Quinn's Excavating, 39 Bog River Bend, Mashpee, MA 02649
Engineering by: SCALE DRAWN JOB. NO.
RUTH KOZLOSKI
/ OWNER OF RECORD EngineeringWorks, Inc. 1"=20' P.T.M. 150-21
P.O. BOX 113 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO.
OSTERVILLE, MA 02655 (508) 477-5313 3/30/21 P.T.M. 1 of 2
NOTE: TO PREVENT ,BREAKOUT, FINAL GRADE
SEPTIC TANK SHALL NOT BE AT, OR BELOW, EL.=97.5
INSTALL RISERS & COVERS OVER INLET & FOR A DISTANCE OF 15' FROM THE EDGE
OUTLET AND SET TO 6" OF FINISH GRADE PROPOSED D—BOX OF THE PROPOSED S.A.S.
INSTALL RISER & COVER PROPOSED S.A.S. 1
SET TO 6" OF GRADE INSTALL RISER & COVER OVER ONE CHAMBER AND
T.O.F=101.2t SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT
F.G. EL.=100.7t F.G. EL.=100.6f F.G. EL.=100.5t F.G. EL.=100.8f EXISTING,
MAINTAIN 2% SLOPE OVER S.A.S. HOUSE(186)
'T.0.F.=101.2t
` L = 85' _ '
S=1% (MIN.) ® s=1% 9MIN.) PORCH
4"SCH40 PVC 4"SCH40 PVC 2" LAYER OF 1/8" TO 1/2"
6" DOUBLE WASHED STONE W
10 I 14„ e" aaa aaa (OR APPROVED FILTER FABRIC) �
2' EFF. aaa8aaaa 0'
EXISTING 48" LIQUID DEPTH aaaaaaa �3/4" TO 1-1/2" DOUBLEd-
GAS +
LEVEL ADD PROPOSED 4' 4.8' 4' WASHED STONE N ,\ 3 �N
� INV.=97.27 _ INV.=97.10 j S3� la
INV.=98.44 �� EFFECTIVE WIDTH = 12.8'
(VERIFY) 3 OUTLETS INV.=97.00 1 ---��
EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS ZrJ'�'�
SURROUNDED WITH STONE AS SHOWN
PROPOSED S.A.S.
H-20 RATED 2-500 GAL CHAMBERS
TOP CONC. ELEV.=98.1 t SURROUNDED W/4' STONE
BREAKOUT ELEV.=97.50
NOTES: INV. ELEV.=97.00 aaaaa SEPTIC LAYOUT
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE aaaaaaaaaaa
aaaaaaaaaaa
INVERTS, PRIOR TO INSTALLATION. BOTTOM ELEV.=95.00
2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE 4' 2 x 8.5' = 17.0' 4'
ON A MECHANICALLY COMPACTED STABLE BASE OR 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH =I 25.0'
SIX INCH AGGREGATE BASE, AS SPECIFIED IN 310 PERVIOUS MATERIAL
CMR 15.221(2). 5' (MIN.) ABOVE G.W. LEACHING SYSTEM SECTION CE3
®® O
3) INSTALL INLET & OUTLET TEES AS REQUIRED. BOTTOM OF TEST PIT, EL.=89.0 ®®®® ® ®®
4) A GAS BAFFLE SHALL BE INSTALLED ON OUTLET TEE F- 37"
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. d• W ®®®EO ® ®®
SEPTIC SYSTEM PROFILE N Z11
102„
SOIL LOG
DESIGN CRITERIA 4" KNOCKOUT
DATE: MARCH 24, 2021 (REF#TPT-21-66)
SOIL EVALUATOR: PETER McENTEE SE#1542 20" DIA. COVER
NUMBER OF BEDROOMS: 3 WITNESS: DAVID STANTON R.S. 1 HEALTH AGENT
SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0.74 GPD/SF) ELEV. TP— 1 DEPTH ELEV. JP-2 DEPTH 4" KNOCKOUT 0
/ 4" KNOCKOUT 58"
DESIGN PERCOLATION RATE: <2 MIN/IN 100.5 0" 100.6 0 1
DAILY FLOW: 330 GPD FILL FILL
DESIGN FLOW: 330 GPD 99'4 A 16" 99.3 A 14" 4" KNOCKOUT
GARBAGE GRINDER: NO—not allowed with design LOAMY SAND ILOAMY SAND
10YR 4/2 110YR 4/2
LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF 98.7 22" 98.9 20" 500 GALLON CAPACITY, H-20 LOADING
.74 GPD/SF LOAMY SAND LOAMY SAND CHAMBERS
EXISTING SEPTIC TANK: 1500 GALLON CAPACITY 97.3 10YR 5/8 38" 97.9 1
10YR 5/8� 32" N.T.S.
PROPOSED D—BOX: 1 INLET, 3 OUTLET (MINIMUM), H-10 RATED C1 ct
PERC
USE 2-500 GALLON LEACHING CHAMBERS IN SERIES + 42"/60" PROPOSED SEPTIC SYSTEM UPGRADE PLAN
SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES MED. SAND M2D5Y /SAN
2.5Y 6/6 86 MIDWAY DRIVE, HYANNIS, MA
SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: Quinn's Excavating, 39 Bog River Bend, Mashpee, MA 02649
BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. 89.0 138" 89.1 138" Engineering by: SCALE DRAWN JOB. NO.
TOTAL AREA:...........................................***
REA:.............................................................. 471.2 S.F. PERC RATE <2 MIN/IN. "C" HORIZON Engineering Works, Inc. N.T.S. P.T.M. 150-21
DESIGN FLOW .PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD NO GROUNDWATER ENCOUNTERED 12 West Crossfield Rood, Forestdole, MA 02644 DATE CHECKED SHEET No.
(508) 477-5313 3/30/21 P.T.M. 2 of 2