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HomeMy WebLinkAbout0135 OAK HILL ROAD - Health . %-!V 135:0ak Mill Road 248; _067 i 001 `Hyannis r I I ,l I� r I I i I° No 1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .f Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Misposal 6pBtem Construttiun permit Application for a Permit to Construct( ) Repair"Upgrade Abandon( ) ❑Complete System 0i1ndividual Components Location Address or Lot No. 1,7T n_ Owner's Name,Address,and Tel.No. Assessor's Map/PazcelZy gj—(� S V--cA n-e.n Installer's Name,Address,and Tel.N . Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms JQA Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) N gpd Design flow provided N40t- 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) `�r L Otno F� S L D a i 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. ff Si Date (9 [ro 11 Application Approved by Date (i 1 .Application Disapproved by Date for the following reasons Permit No. '00 1ct —006 Date Issued /0 ---------------- n } 3 Feed THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye . PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pptiration.for, Disposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. �� 0/f H ( 2 Owner's Name,Address,and Tel.No. Assessor's Map/ParcelZy _ Wjng-,-CQI . M-�S A �Z O 611\ VXcn n.t Installer's Name,Address,and Tel.No. I Designer's Name,Address,and Tel.No. 5 cv) C-,C-C \,V_ `_(NcLYN�, 2 d Type o Building: Dwelling No.of Bedrooms � { Lof-Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided IV A_ 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) r 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 Environmenta�de'and riot to place the system in operation until a Certificate of r. Compliance has been issued by this Board of Health. " Signe4L Date G Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 2—O 1! _ 006 Date Issued ----------------------------------------------------------------------------- --------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS VvR e BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(VI Upgraded( ) i Abandoned( )by at Chas been constructed in accordance with the provisions of Title 5 and the for Disposal Syste Construction Permit No/-_b1_-CL— dated 4oll Installer �8 —C �V Designer #bedrooms /V/Q� Approved design flow q/ ( gpd The issuance of this ermht shall not be construed as a guarantee that the system will ction as d/e gned. Date �„ � m Inspector cY -------=------------------------------------------------------------------------------------------------------------------------------- No. e2n —f C/lp Fee v U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal &pstem Construction Permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at 1 1T O W4 14 1 f3d 4, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pe Date (n�(n �� /� Approved by � C/ IS5 11zN' On Family Room Patio ! 161X18' 11'X1 ' 8 Mud .. Room � f 15'x9' 10'x9Sitting' i 1� T� Room Bejdroom aster Bedroom Mas er -J" l 10'X12' 14'X11' 12 X10 Bedroom 5►x4► 12'X14' y. 5,x4, .\. Breakfast -- f\I Garage Nook : ��� _hf Garage �� 13'x23' Tj Living i 131x16' Dining --- Room F o Room 19'x14' 2-0 Kitchen \� Foyer 12 X12 { 141x7 0 -st4oV--C ALARM c Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Oak Hill Rd. a Property Address �e�K,'RU berr4 ?0 Owner Owner's Name `w information is H annis ✓ Ma. 02601 June 21, 2018 required for every y page. Cityrrown State Zip Code Date of Inspection r i6 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms s' �3 f 03 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Thomas Roux use the return Name of Inspector key. 4:1 Company Name 89 Mayflower Lane Company Address East Wareham Ma. 02538 Cityrrown State Zip Code 774-678-9066 S14531 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �- JUAR )elf Inspector's Signature Date The system inspector sha11 submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. - t5ins.doc-rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System,-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form jn Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 135 Oak Hill Rd. Property Address Paul & Lynne Ingraham Owner Owner's Name information is Hyannis Ma. 02601 June 21, 2018 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any.information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"ConditionalPass" 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): F t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 135 Oak Hill Rd. 'u Property Address Paul & Lynne Ingraham Owner Owners Name. information is Hyannis Ma. 02601 June 21, 2018 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ON ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within,50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6116 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Oak Hill Rd. Property Address Paul & Lynne Ingraham Owner Owner's Name information is required for every Hyannis Ma. 02601 June 21, 2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. , ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Oak Hill Rd. Property Address Paul & Lynne Ingraham Owner Owner's Name information is required for every Hyannis Ma. 02601 June 21, 2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.). Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact\the Board of Health to determine what will be necessary to correct the failure. E) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—1WPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6116 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Oak Hill Rd. Property Address Paul & Lynne Ingraham Owner Owner's Name information is required for every Hyannis Ma. 02601 June 21, 2018 page. Citylrown 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? ® ❑ Wasthe 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): No design Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): +330 gpd t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts �n Title 5 Official Inspection . Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Oak Hill Rd. Property Address Paul & Lynne Ingraham Owner Owner's Name information is required for every Hyannis Ma. 02601 June 21, 2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2017 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6116 ,Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 7 of 17' IL Commonwealth of Massachusetts Title 5 Official Inspection Form 1 e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Oak Hill Rd. Property Address Paul & Lynne.Ingraham Owner Owner's Name information is required for every Hyannis Ma. 02601 June 21, 2018 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: No records 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): Two cesspool structures in series. a t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 135 Oak Hill Rd. Property Address Paul & Lynne Ingraham Owner Owner's Name information is Hyannis Ma. 02601 June 21, 2018 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 58 years, House was built in 1960. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 2, Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ® other(explain) The first cesspool acts as the septic tank. The structure is made of concrete and stone blocks. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6' in Dia. x 7' in Height Sludge depth: t5ins.doc•rev.6/16 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 135 Oak Hill Rd. Property Address Paul & Lynne Ingraham Owner Owner's Name information is required for every Hyannis Ma. 02601 June 21, 2018 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 5'+/- Scum thickness none Distance from top of scum to top of outlet tee or baffle 4.5+/ Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? measured 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 first cesspool acts as the septic tank.The structure is made of concrete and stone blocks.The structure does not need to be pumped out at this time. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 17 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 135 Oak Hill Rd. Property Address Paul & Lynne Ingraham Owner Owner's Name information is required for every Hyannis Ma. 02601 June 21, 2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No . t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments 135 Oak Hill Rd. Property Address Paul & Lynne Ingraham Owner Owner's Name information is required for every Hyannis Ma. 02601 June 21, 2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert N/A 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.): There is no D-Box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes , ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Cesspool#2 acts as the SAS. This structure was completely dessicated at the time of inspection, with no evidence of hydraulic failure. 4 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 L Commonwealth of Massachusetts Title 5 Official� Inspection ction Form p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 135 Oak Hill Rd. Property Address Paul & Lynne Ingraham Owner Owner's Name information is H annis Ma. 02601 June 21, 2018 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers r number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ 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.): This structure was completely dessicated at the time of inspection, with no evidence of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction ` Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form 1' a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 135 Oak Hill Rd. Property Address , Paul & Lynne Ingraham Owner Owner's Name information is required for every Hyannis Ma 02601 June 21, 2018 page. Cityffown 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.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 135 Oak Hill Rd. Property Address Paul & Lynne Ingraham Owner Owner's Name information is Hyannis Ma. 02601 June 21, 2018 required for every y page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below n �T El drawing attached separately _� y AV 15 A to cesf �m 6fo to ce st ,00( #� A SP a�� Ce Sao eeSsP p0.: , 1B- �T � m .: UM FH AGAR 3 o� t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v V< 135 Oak Hill Rd. Property Address Paul & Lynne Ingraham Owner Owner's Name information is required for every Hyannis Ma. 02601 June 21, 2018 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: below 13' 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: pate ® 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: Dug a test hole onsite. See attached soil report. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 135 Oak Hill Rd. Property Address Paul & Lynne Ingraham Owner Owner's Name information is required for every Hyannis Ma. 02601 June 21, 2018 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 CeS o o b m i.t IV f • rt4 ,Qf— -fo ceSfP� /Vic� Pav-(4mr, o—F c • AlTf 2 ri s2� 7 ' �3 � kde �jc.,-r du HI-e-1W -� se u J s+Tv tu VLo eo of 9 r • • Commonwealth of Massachusetts City/Town of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal A. Facility Information Paul & Lynne Ingraham Owner Name 135 Oak Hill Rd. Street Address Map/Lot# Hyannis Ma. 02601 City. State Zip Code B. Site Information 1. (Check one) ❑ New Construction ❑ Upgrade ® Repair 2. Soil Survey Available? ® Yes ❑ No If yes: Website MA Source Soil Map Unit Carver Coarse Sand Soil Name Soil Limitations Loose Sandy Glaciofluvial Deposits Outwash Plains Soil Parent material Landform 3. Surficial Geological Report Available? ❑ Yes® No If yes: Year Published/Source Map Unit Description of Geologic Map Unit: 4. Flood Rate Insurance Map Within a regulatory floodway? ❑ Yes ® No 5. Within a velocity.zone? ❑ Yes ® No 6. Within a Mapped Wetland Area? ❑ Yes ® No If yes, MassGIS Wetland Data Layer: Wetland Type 7. Current Water Resource Conditions (USGS): Range: ❑ Above Normal ❑ Normal ❑ Below Normal Month/Day/Year 8. Other references reviewed: t5form11 Ingraham•rev.3/15/18 Form 11 -Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 5 Commonwealth of Massachusetts City/Town of Barnstable Form 11 Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed primary and reserve disposal area) Deep Observation Hole'Number: DTH-1 June 21, 2018 1:00 P.M. sunny Hole# Date Time Weather Latitude Lonqitude: wooded trees None 0-3% 1. Land Use (e.g.,woodland, agricultural field,vacant lot,etc.) Vegetation Surface Stones(e.g.,cobbles,stones,boulders,etc.) Slope(%) Description of Location: 2. Soil Parent Material: Loose Sandy Glaciofluvial Deposits Outwash Plains Landform Position on Landscape(SU,SH,BS,FS,TS) 3. Distances from: Open Water Body +100' feet Drainage Way +100' feet Wetlands +100' feet Property Line +20' feet Drinking Water Well +100' feet Other feet 4. Unsuitable Materials Present: ❑ Yes ® .No' If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed:❑ Yes ® No If yes: Depth Weeping from Pit Depth Standing Water in Hole Soil Log Redoximorphic Features Coarse Fragments° Soil Soil Horizon Soil Texture Soil Matrix:Color- /°b Volume Depth(in) Soil Structure Consistence Other /Layer (USDA Moist(Munsell) Depth Color Percent Gravel Cobbles& (Moist) Stones 0"-5" O/A Sandy Loam 10YR2/2 5"-14" B Sandy Loam 10YR5/8 14"-135" C1 Band ar 10YR7/7 135"- C2 Coarse 10YR8/3 160" Sand Additional Notes: No evidence of water table. t5form11 Ingraham•rev.3/15/18 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 5 Commonwealth of Massachusetts City/Town of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review(minimum of two holes required at every proposed primary and reserve disposal area) Deep Observation Hole Number: Hole# Date Time Weather Latitude Longitude: 1. Land Use: (e.g.,woodland,agricultural field,vacant lot,etc.) Vegetation Surface Stones(e.g.,cobbles,stones,boulders,etc.) Slope(%) Description of Location: 2. Soil Parent Material: Landform Position on Landscape(SU,sH, BS,FS,TS) 3. Distances from: Open Water Body - feet Drainage Way feet' Wetlands feet Property Line feet Drinking Water Well feet Other feet 4. Unsuitable Materials Present: ❑ Yes ❑ No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Weathered/Fractured Rock ❑ Bedrock 5. -Groundwater Observed:❑ Yes ❑ No If yes: Depth Weeping from Pit Depth Standing Water in Hole Soil Log Redoximorphic Features Coarse Fragments Soil Depth(in) Soil Horizon Soil Texture Soil Matrix: %by Volume Soil Structure Consistence Other /Layer (USDA) Color-Moist Cobbles 8(Munsell) Depth Color Percent Gravel Stones (Moist) Additional Notes: t5form11 Ingraham•rev.3/15/18 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 5 Commonwealth of Massachusetts City/Town of Barnstable y` Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1., Method Used: Obs. Hole# Obs. Hole# El Depth observed standing water in observation hole inches inches ❑ Depth weeping from side of observation hole inches inches ❑ .Depth to soil redoximorphic features (mottles) inches inches ❑ Depth to adjusted seasonal high groundwater(Sh) inches inches (USGS methodology) Index Well Number Reading Date Sh = Sc—[Sr x (OWE—OWmax)/OWrl Obs. HoleNVell# SC Sr OWE OWmax OWr Sh 2: Estimated Depth to High Groundwater: inches E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ® Yes ❑ No b. If yes, at what depth was it observed (exclude A and O Upper boundary: 14" Lower boundary: 160" Horizons)? inches inches c.. If no, at what depth was impervious material observed? Upper boundary: Lower boundary: inches inches t5form11 Ingraham•rev.3115/18 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 5 Commonwealth of Massachusetts City/Town'of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal F. Certification I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. 1 further certify that the results of my soil evaluation, as indicated in the attached Soil Evaluation Form, are accurate and in accordance with 310 CMR 15.100 through 15.10Z. \, 1'# /�� June 21, 2018 Signature of Soil Evaluator Date Thomas Roux/-SE2703 April 2019 Typed or Printed Name of Soil Evaluator/License# Expiration Date of License Name of Approving Authority Witness Approving Authority Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and to the designer and the property owner with Percolation Test Form 12. Field Diagrams: Use this area for field diagrams: Ti T t5form11 Ingraham•rev.3/15/18 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 5 I� Commonwealth of Massachusetts ti Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �_� M y0 135 Oak Hill Road Property Address p, Robert Herrick Owner Owner's Name --j information is 02601 7/18/2017 M Hyannis a required for every H y � � 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/18/2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 orfk"J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 . page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 135 Oak Hill Road Hyannis is served by a septic system consisting of a block cesspool with a block cesspool overflow. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N El 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 a 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M yvey`•r 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 page. City/Town State Zip Code Date of Inspection B. Certification. (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts L - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,boogpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310,CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 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? E. El available as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SVO,� 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 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: t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,a' 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official hspection 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 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: original 1960 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ❑ 40 PVC orangeburg ® other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts L v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every y H annis Ma 02601 7/18/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is Hyannis Ma 02601 7/18/2017 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u v d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , y 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ 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.): Overflow cesspool was in good structural condition with no loose blocks. Cesspool was dry with no signs of past hydraulic overloading. Cover is a grade. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert 2' Depth of solids layer 6" Depth of scum layer 0" Dimensions of cesspool 6x6 Materials of construction cesspool block 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 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): cesspool was in good condition, water level was 2' below inlet pipe. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately &p.IAGE;�4 � (0 �Z �3 t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. 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 135 Oak Hill Road Property Address Robert Herrick Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2017 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 I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 LOCATION . 5E o,GE PERMIT UO. IW5TALLER'S U E DR S _ _ -BUILD-ER S_- SS _ Dt�,TE .PERNAIT .ISSUED 2 7 j— __ -_D.AT.E COKAPLI-AKiCE ISSUES :-_ _ = -- V . a ti r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... ........................... `Appliration -for Dig oiial Works Tonfi#rurtion Vrrmit PApplication is hereby made for a Permit to Construct ( or Repair ( } an Individual Sewage Disposal System at: g R® NY,4 ,j, CjP}k �.11 � , . L n r ss o Lot No. ..---•--•--hlo / .. ?�►'� ------------------------------------ ---J` ----� ' ---.dill-, ® ... l �` + --•------------ Installer Address Type of Building Size LotJ---._:� f .....Sq. feet U .� Dwelling—No. of Bedrooms,-qg------------------------------•..........Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building .-fs_R• e�}_-...-.-. No. of persons__.--_--a�-------------- Showers (�) — Cafeteria ( ) Pa Other fixtures ------------------------------------------------------ W Design Flow.....---.�®..........................gallons per person per day. Total daily flow-------------/00................-----.__gallons. WSeptic Tunk—Liquid capacity-_.-------gallons Length---------------- Width..---........... Diameter-----........... Depth.._...,._...--. 1 x Disposal Trench—No--------------------- Width_------------------ Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No./t�®a_-YAL-Diameter---4............. Depth below inlet---.--........... Total leaching area.. ®gt-..sq. It. Z Other Distribution box ( ) Dosing tank (, ) ~' Percolation Test Results Performed by--------------------...................................................... Date--------------------------------------- ,� Test Pit No. 1......----------minutes per inch Depth of "Pest Pit._-.--_----------- Depth to ground water.._--__..._.-..._..._.- (i Test Pit No. 2................minutes per inch Depth of Test Pit..-------------.---. Depth to ground water....-.-------.-.....__._ a. -- ---------------------------------------------- ODescription of Soil na 4C -------------------------------------------------------------------------------- -----------=-------- ---------------------------------------------------------------------------------------------- ® ,--------- - ----- - ------------ - U = Nature of P.epairs or Alterations—Answer when applicable.....- .1J. - --_ ------.._--/Q ------- -------------------------------------------=-------------------------------------•----------..-...----------------...----------......---------------..-...------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions,of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by�the board of health. Sed .. ------------- Datte Application Approved By=-. � Date Application Disapproved for the following reasons:................... ---••--------------•-----•-•--........................................ ...--------•-- -------------------------------------------------------------------------------------•-•----------------_.-----------------------------------------------=----------------------- ---------------------- Date �� P7S_ PermitNo......................................................... Issued...... -- --/------•--------•-----•------------- Date THE COMMONWEALTH OF. MASSACHUSETTS \ ' .BOAR HEALTH 4 � I , s lirtttinn for Buipmal Wofko Tonotrurtivu Vrrmit Application is hereby made fora Permit to Construct (~; or Repair ( ) an Individual,Sewage Disposal System`at 04/C ! 1/r Rb q t) Nvj#riw - ----- ---•----•--------- --------------- - Lo a ess } s _. -_-•-_-__-----•-------------------------------------------- ------- - ----------------- Address /.. ,�tpy►," i'.e egx.14-------- Installer Address U Type of Building t' Size feet Dwelling—No. of Bedroom ...........................::............Expansion Attic ( ) Garbage Grinder` ( '�)•' At F} a . Other—Type ..of Building ______________________.____.. No. of persons..___._---------------- Showers (� ) Cafeteria-( ) Othf.�Ktures ------------------------------------------------------------------------------------------------------------------=------------ -------------••------ Design Flow.._._. ....:.........................g _allons per person per day. Total daily flow___--___`_ as-- ______.-___--..----- gallons. W ...Length---------------- Width--- --- -_ Diameter---------------- Depth------- - ------ a W Septic Tank—Liquid capacity___________gallons x Disposal Trench-- X0 _______________ Wic],tli... __-_-_--_ Total Length_..................;Total leaching area....:---_-.: -__--sq. ft. ' (�" -_ Depth below inlet____ Total leachin area �,tQr1____sc ft. Seepage Pit No..b, � Diameter______-:__-- P � g t v� I• >%z Other Distribution box '(�` ) Dosing tank (. ) Percolation Test Results Performed by------- -----------------........................................---------- Date.......--------------------- tiw ,aa Test Pit No. I _ rninutes per inch Depth of lest `Pit_._.:.............. Depth to ground water_----_--._ .:Test Pit No. 2.................minutes per inch. Depth of";,lest Pit._ V____________ Depth.to grquric water............... a= -= / 9, r - Deception of Soil.-:-_-_--._ A �........................... ------------------- - � `� -44 U Nature of Repairs or Alterations—Answer when applicable_.O.Ll Q._�_.._0----------------------------------------__, ---._-_-.... ------=----- ----------------------------------------------------- ---------- .................................... ------------------................- ------------------------ ----- Agreement: ". ` a,A The 'undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code The undersignedVr �rl rees not to place the system inoperation until a Certificate of Compliance t ]p¢ ilp1su� f h . ` n a I Application Approved By �----- ... . = u' `V ----- ---------_-- -------------/� - " Date Application Disapproved for the following reasons: .....:............................................................................................. f" ................................................... -----------------------------------------------------•-•-------•-----------------------•---------- ---- Date e Permit No.... -----------------••• -------••••-•----.:... Issued.--= ... s'-;'"---- Date, ` THE COMMONWEALTH OF MASSACHUSETTS " 'BOARD HEALTH . t� r 'Trrtif'rate �vf :fimlirr r h T IS 1 O CF " I FY That th04 e�e In viduaI' a age is osal System constructed ( rt ) or Repaired ( � ), ----- --- Installer F- < . r1 has been installed in accordance with the provisions'of _ c1 I State Sanittlry de as scr i=t he M applicationt:for Disposal Works Construction Permit .._..... dated................................... . THE ISSUANCE OF TEAS CERTIFICATE SHALL NOT BE CONSTRUED A A GUARANTEE T�IAT THE S*STEM .WILL. UNCTION SATISFACTORY. i DATE . ---------------- Inspector-- .- y1. n. n } THE'COMMONWEALTH,'OF_�v1AS5A'CHUSETTS' BOARD O HEALTH 2, No. . . '`" . - FEE I t ` r Permissiori1§, hereby granted,_"' -----=-•--------------)� ---------- ,... h --•--••••• . to Construct )�. ep ( ndi u Sewa= s 1 Syste GLC.,a. � �-� !I.._/_/// itt • treet s1. t as-shown on the application for Disposal Works Constru.ctio mit _ Date __ 1' :. �.. 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