Loading...
HomeMy WebLinkAbout0253 MITCHELL'S WAY - Health t 253 Mitchell's. Way Hyannis A=290—049 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 253 Mitchells Way Assessor's Map 290 Parcel 49 Property Address Gerald T. McDowell Owner Owner's Name information is required for every Hy annis� MA 02601 March 28, 2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any _ way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: _ key to move your cursor-do not use the return David D. C,oughanowr, IRS - Name of Inspector key. Eco-Tech Environmental` Company Name P.O. Box 1265 Company Address West Chatham MA 02669 City/Town State Zip Code 508 364-0894. 1328 Telephone Number License Number B Certification , certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site' sewage disposal systems. I am a DEP approved system inspector pursuant to Section•15.340 of Title 5(310 CMR 15.000). The system: 0 .Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority dj March 28, 2014 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. l5ins•3/13 Title 5 Official Inspection Form:Su urface Sewage Disposal System•Page 1 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 253 Mitchells Way Assessor's Map 290 Parcel 49 Property Address Gerald T. McDowell Owner Owner's Name information is required for every Hyannis MA 02601 March 28, 2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or gua-antee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: One or mores stem components as described in the"Conditional P Ely p ass section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 253.Mitchells Way Assessor's Map 290 Parcel 49 Property Address _ Gerald T.McDowell Owner Owner's Name information is required for every Hyannis MA 02601 March 28, 2014 page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due •--to„broker 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 requited pumping more tha n,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): 7-1 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. 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: El Cesspool or privy is within 50 feet of a surface.water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 253 Mitchells Way Assessor's Map 290 Parcel 49 Property Address Gerald T. McDowell Owner Owner's Name information is required for every Hyannis MA 02601 March 28, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1.of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded o- 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 Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 253 Mitchells Way _Assessor's Map 290 Parcel 49 - Property Address Gerald T:McDowell ' Owner Owner's Name information is required for every Hyannis ? _ MA 02601 March 28, 2014 page. CityTrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. El '® Any'port ion of cesspool'or privy'is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® 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 ammo'nia_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.] 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 10;000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure.- E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200.feet of a tributary to a surface drinking water supply the system,is located in•a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mappedZone II of a public water supply well If you have-answered "yes"`to any question in Section E the system is considered a significant threat, or,answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 253 Mitchells Way Assessor's Map 290 Parcel 49 Property Address Gerald T. McDowell Owner Owner's Name information is required for every Hyannis MA 02601 March 28, 2014 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA.) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the cordition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information.,For example, a plan at the Board of-Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 253 Mitchells Way Assessor's Map 290 Parcel 49 Property Address Gerald T. McDowell Owner Owner's Name information is 1 ; required for every Hyannis MA 02601 March 28,'2014 page. Citylrown K State Zip Code Date of Inspection D. System Information Description: System was installed by Rodney Fisher in 2009. O Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system.inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available. last 2 ears usage 137 gpd 9 ( Y 9 (gpd)) Detail: 2012: 67,325 gallons 2013: 32,914 gallons Sump pump? ❑ Yes Z No Last-date of:occu panc -. :., 6 month ago , Y .,:. 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?.,a ❑ 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: l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System<Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-'Not for Voluntary Assessments °M 253 Mitchells Way Assessor's Map 290 Parcel 49 Property Address Gerald T. McDowell Owner Owner's Name information is required for every Hyannis MA 02601 March 28, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner's agent Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 253 Mitchells Way Assessor's Map 290_Parcel 49 ,. Property Address Gerald T. McDowell y i_ Owner Owner's Name � information is required for every. Hyannis-" r r MA 02601 March 28, 2014 . page. City/Fowrt State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known) and source of information: 4+ years. Certificate of Compliance for new distribution box and leaching facility issued 9/25/2009 (Permit#2009-299). Were sewage odors detected when arriving at the site?A ❑ Yes ® No Building Sewer(locate on,site plan); 3 . Depth below grade: feet k Material of construction: ❑ cast iron ® 40 PVC ❑.other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank (locate on site plan): Depth below grade: 2.5 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: 8.5 x 5 x 6-1000 gallon Sludge depth: 10 in t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 253 Mitchells Way Assessor's Map 290 Parcel 49 Property Address Gerald T. McDowell Owner Owner's Name information is required for every Hyannis MA 02601 March 28, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 in Scum thickness trace Distance from top of scum to top of outlet.ee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is not required at this time. Maintenance pumping is recommended within 2 years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade:p g feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System form -,Not for Voluntary Assessments 253 Mitchells Way Assessor's Map 290 Parcel 49 Property Address _ Gerald T. McDowell _ Owner Owner's Name information is required for every Hyannis " f MA. 02601 March 28, 2014 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.): i Tight or Holding Tank(tank must be pumped at time'of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete- ❑-metal - - -❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day .Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 253 Mitchells Way Assessor's Map 290 Parcel 49 Property Address Gerald T. McDowell Owner Owner's Name information is required for every Hyannis MA 02601 March 28, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc:.): Camera inspection showed no adverse conditions. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 S ^ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 253 Mitchells Way Assessor's Map 290 Parcel 49 Property Address Gerald T. McDowell Owner Owner's Name information is required for every Hyannis MA 02601 March 28, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) g -Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: leaching fields number, dimensions. 1 field -8.5'x 32' ❑ 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.): Soils above leaching area appear unsaturated. No evidence of surface ponding, breakout; lush vegetation, or other evidence of hydraulic failure was observed. Field consists of 24 Quick 4 Standard Infiltrators per design plan. -Cesspools.(cesspool must be pumped as part.of inspection) (locate on,site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer ----- Dimensions of cesspool --- -- - Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 253 Mitchells Way Assessor's Map 290 Parcel 49 Property Address P Y Gerald T. McDowell Owner Owner's Name information is required for every Hyannis MA 02601 March 28, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 253 Mitchells Way Assessor's Map 290 Parcel.49 Property Address - Gerald T McDowell Owner Owner's Name information is required for every l-lyatlnlS MA 02601 March 28, 2014 page. CityfTown " State Zip Code Date of Inspection D. .System'fnformation (cont ) Sketch Of Sewage Disposal System: Provide'a view of.the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate Where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below 0 drawing attached.separately /L1�/�n /] ��Q � M IIVIL� TC UI� L� L—S VV A 11 INFILTRATOR LEACHING FIELD Q m THIS SKETCH IS o BEST VIEWED IN ¢, COLOR FORMAT • 3 0 , • Q CA- A. EXISTING WATER LINE DWELLING 2 1 OF 253 1000 GALLON.; .SEPTIC TANK B LOCATIONS o 70F SEPTIC COMPONENTS - \ DISTANCES IN DECIMAL,FEET A 8 � • 1 39.5 41 . . 2 45 47.5 . .. .. o r 3" 45 62.5 508 364-0894 t5ins-3113 Title 5 Official.Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ° M 253 Mitchells Way Assessor's Map 290 Parcel 49 Property Address Gerald T. McDowell Owner Owner's Name information is required for every Hyannis MA 02601 March 28, 2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 11+ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 9/15/2009 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: Approved design plan on file with the Board of Health shows bottom of system to be 5 feet above the bottom of a witnessed test pit in which no water or groundwater mottling was encountered. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 253 Mitchells Way Assessor's.Map 290 Parcel 49 Property Address Gerald T. McDowell Owner Owner's Name information is .required for every Hyannis MA 02601 March 28, 2014 - page. City/Town State Zip Code Date of Inspection E. Report-Completeness Checklist ® inspection Summary: A, B,,C, D, or E checked ® Inspection Summary D (System Failure Criteria.Applicable to All Systems) completed System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file.. GEOHYDROLOGICAL PROFILE - NOT TO SCALE BOTTOM .Of -- LEACHING PER DESIGN PLAN . +. LEACHING IS aD v- ABOVE HIGH GROUNDWATER YI GROUNDWATER g. ADJUSTMENT----3.3 v POND ELEVATION PER DESIGN PLAN � 3 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town of Barnstable r# -2 Department of Regulatory Services l Public Heal 1 7 wuwer,►st8 : th Division Date 39.� 1a �6 200 Main Street,Hyannis MA 02601 prED MAt� f, . s Date Scheduled a Time Fee Pd. (04 Soil Suitability.Assessment for Sewage l isposal Performed By: Witnessed By: n �S LOCATION& GENERAL INFORMATIO Location Address 313 3 P11i S coC.\1J Owner's Name � Address 111 Assessor's Map/Parcel: . 010 - 0�1 Engineer's Name G", sy-,. NEW CONSTRUCTION REPAIR Telephone# $3 Q Land Use �1 (O t Q'A Slopes(40) 5L07¢3 Surface Stones Distances from: Open Water Body ` ft Possible Wet Area ft Drinking Water Well A1114- ft t Drainage Way �! 9` ft Property Line �� ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)' #f i 0ei T. 1�t r+ael ' Parent material t7 �" (geologic) c Depth to Bedrock C> p ge(�C .��5' Weeping from Pit Face e Depth to Groundwater. Standing Water in Hole: t Estimated Seasonal High Groundwater 2 - �JS DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: _ in, Depth to soil mottles: J C3"d Depth to weeping from side of.obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj,factor- Adj.Groundwater Level PERCOLATION TEST bate " I Time...A11:oa Observation Hole# I Time at 9" 3 M i t7 Depth of Perc =V Time at 6" �?�� ro to r , Start Pre-soak Time @ I . 1 5 Time(9"-6") End Pre-soak-. •. ' Rate MinJlnch L M P Site Suitability Assessment: Site Passed iy� Site Failed: Additional Testing Needed(Y/N) h Original: Pubic Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1)week prior to beginning. Q:\SEPTICVERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency.% ravel O P)n S L ore.31,, 0 Pa ' `i0 (Z SIC_ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soii Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C nsis en % ravel (0 3 'R> DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consi t n ° Flood Insurance Rate Map: Above 500 year flood boundary No— YeVK Within 500 year boundary No! Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on dat sed the soil evaluator examination approved by the Department of Environ en Pr t tion n at a above analysis was performed by me consistent with the required training,exp tise and xperi c des ribed in 310 CMR 15.017. Signature Date , Q:\SEPTICIPERCFORM.DOC ASSESSORS MAP NO: -- 26 �N 0 PARCEL NO.• No.��1."3�y�� a Fps..�........�.-... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r / vs '........ Apli iratien for Uiupviitt1 30urkii Tunitrurtiun V ernti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 9S3 _ ....:... 1........ t ._..... ^1---------------- ............................................(......---..... .fir ww�s.----•------- �S Location-Address or Lot No. ....... ... .. —........►�. 0--- -� ' \................................ . ....................... Q.... .......------........---------................ Address --------------- --- ... �................ .......... .. ............... Installer Address pq 4 Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.__...3.................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building ............... No. of ersons._.....__......_.....__.__.. Showers — Cafeteria a YP g ------------- P ( ) ( )y G4Other fixtures ......................................................-------------•--------••------------------------------------...--•--...----•-----.............. d W Design Flow............S ...................gallons per person per day. Total dai17 flow......... ................gallons. WSeptic Tank L Liquid capacitv..1.0.®U-gallons Length...... -...... Width................ Diameter________________ Depth................ x Disposal Trench—No. .................... Width..._... ............ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......f------------ Diameter...... ,�?........ Depth below inlet................ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '~ Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ....-•--•--------------------•-------.............................-•------------•--•------------.....•....-•-------.........---•--....------•-•-•-----•-..... 0 Description of Soil........................................................................................................................................................................ •----------•-------- ..........................----------•-----------------------------------•------------------------------------•------•---------.....-----•-------------------------•------•---•---- U Nature of Repairs or Alterations—Answer when applicable---:%'71V`:TW. J._ .(l,enem!__.7-1 T4 r--.W.................. f.C1-P- ?, � '�� Tom- K; �1_.._l oY.. fl �Z /�� -.. '..,5 --- ---•----------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITIE 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Complian ed by the board o at . Sied...--... ----- ----------------- ------------- ......... ----lL Application Approved BY----------- t _���. t " ate Application Disapproved for the following reasons-.................................................... --...-----•--•--...... -----•-•--••--•...............•-•--•-----•------•-----------•...----•----------••-•---.......-------•--...................-------------------------------------------------------------------••-•-------. Date PermitNo.._......... = ....... Issued-....................................................... Date No '. Fim........................... THE COMMONWEALTH OF MASSACHUSETTS - V:.�r� tovy.�!.........OF.....-.:. . �1/ r...................................•- Applirtttion for Iligpusttl Warkii Tonstrur#inn Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: t\ ,. .......Gx I........y �1' �1Sk\s�---.:.5�!�!4`�.......-•-•------ -••............... 0....�'�..-.� . ���'.wve"�S•---• �� Lo//caat-�tion.Add resi or Lot No. •- Address ....�r •� .....n �"r .............. S .af ...3:!!..... .................. .............. ........... Installer Address UType of Building Size Lot...........................Sq. feet Dwelling—No. of Bedrooms__..��..�►'...................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building .............. No. of ersons............................ Showers� yP g ----•------------••------•-----------------P--- ( ) — Cafeteria � ) Other fixtures ..__... €.. W Design Flow........... Jam....................gallons per person per day. Total daily flow.........r�.. ._ .......................gallons. WSeptic Tank�Liquid capacity.10� .gallons Length_.. :.......Width...`{......._ Diameter................ D-epth................ x Disposal Trench—No. .................... Width....... ......_..._.. Total Length............ Total leaching area.....t.._._.._......sq. ft. If r---•- 3 Seepage Pit No......I............ Diameter.__.1.3........ Depth below inlet.... .......... Total leaching area_t..............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by.......................................... :..... ...... Date....... ....................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.--------------- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......................... a' -----------------------------•----..........-------•-----•--------•-•-•---•--•--...-.-----------...............................-=......•••........---•-.._... 0 Description of Soil.......................................................................................................................................................................W V ------•-----' ----------------• -----------------.--------------------------------- --------------------------------- -------- -.--•----------------- .._...--------- .........-------------------------------- W U Nature of Repairs or Alterations—Answer when applicable ;V&STW 7r -_--_-•_•.•_•_.- e �`" ? P��" •`'` ` ............................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITU 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliances kaV-been d by the bo rd f alth Si ed_ ^ ?(�P .__...�: te! .__.... .... .................. ........ r. ~• {'� Application Approved By........`'"" ..: .r_.._ -� .:►.F_ .. ... .... ..... at Application Disapproved for the following reasons:-------•-------•----•---------------•-----.........-•--------•--•-----------•--•-------...........•--•••---•--- --•-•-•--••---•---------•--------•-----•----•---•-••--------------------------------------•-----•---------•--•••--••----•-------...----------------------•-•---••...................................... Date Permit No................ ,�` 'w .,: - - Issued........................................ --- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... ....................... ............................. ......... Trrtif irtttr of Tnntplittnrr THIS IS TO CERTIFY, That ual Sewage Disposal System constructed ( ) or Repaired by........................... '� �j �= .....� l2AIr.-•-------•---•-------••-=----•-------•----•----•.......................•...------•--•-----------_ / Insl`er i ! has been installAd in accordance with the provisions of TI TFr 5 of The State Sanitary Code as described in the application for Disposal. Works Construction Permit No.......W ..._... ....... dated___..!-_.7-SA-G------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNC ION SATISFACTORY. �—�-- DATE----------------•-•--q•-22_- .......................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD ©©OF HEALTH ...... .....OF........! ' ................................ No F$E.. ��tt�r#iun �rrntit Permission is hereby granted----•-......-•= -°=' �' o` = .°....."... .. .......................................................... to Construct ( ) or Repair ( C)-an Individual Sewage Disposal S s em at No............. I.........•f �`t.7 �.!'� ..... i/_Cr. s�',5........... ... Street as shown on the application for Disposal Works Construction Per Board of Health *"'" '"• DATE......................of ..... .--- l.� " o.------.FORM 1255 A. M. SIN, INC., BOSTON �ti