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HomeMy WebLinkAbout0256 OAKLAND ROAD - Health �J Oaklandoc��l Hyannis A=271-129 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v�. 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Na ~� information is me required for every Hyannis MA 02601 7/28/2017 page. City/Town State Zip Code Date of Inspection 1`0 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 /a on the computer, use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services my Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 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 8/4/2017 nspector'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 ��� V� Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Oakland Rd. Property Address Jeffrey Rudziak. Owner Owner's Name information is required for every Hyannis MA 02601 7/28/2017 - 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: System in working condition. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments y 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name information is required for every Hyannis MA 02601 7/28/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins 3113 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 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name informati required onfor ev is.ery Hyannis MA 02601 7/28/2017 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a 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 '/Z day flow t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts G Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name information is required for every Hyannis MA 02601 7/28/2017 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. El ® 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 falls. 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 lI 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 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts 4 v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name information is required for every Hyannis MA 02601 7/28/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 110x3= 330gpd t5ins•3113 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 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name information is required for every Hyannis MA 02601 7/28/2017 page. Cityrrown 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)): 2015=23gpd 2016=29gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name information is required for every Hyannis MA 02601 7/28/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name information is required for every Hyannis MA 02601 7/28/2017 - page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1979 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 16"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: 1500Gal Sludge depth: 3-5" t5lns•3113 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 "A 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name information is required for every Hyannis MA 02601 7/28/2017 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 0-2" 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? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal H-10 tank in good condition. PVC tees in place and clean. Tank at normal operating level. Inlet cover 16" below grade with outlet 10" below grade. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form 's Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name information is required for every Hyannis MA 02601 7/28/2017 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.): 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rY 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name information is Hyannis MA 02601 7/28/2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): o„ 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.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solids carryover. No sign of overloading or hydraulic failure. Cover 8" below grade. 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): ti If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name information is Hyannis MA 02601 7/28/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6x6 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.):- 1-6x6 Pit with stone. 2'of effluent in pit at time of inspection with no visible staining above current leve. No sign of overloading or hydraulic failure. Cover 16" below grade. Note asbuilt on file at town shows two pits. Only one line leaving box and only one pit installed on this system. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name information is required for every Hyannis MA 02601 7/28/2017 page. CitylTown 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts 4 r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments ." 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name information is MA 02601 7/28/2017 fired for everyHyannis Date of Inspection required Cityrrown State Zip Code p page. D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owners Name information is required for every Hyannis MA 02601 7/28/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +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: Hand auger to 12'with no water encountered. Bottom of pit at 8'. 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 "< 256 Oakland Rd. Property Address Jeffrey Rudziak Owner Owner's Name information is Hyannis MA 02601 7/28/2017 rpe aired for every Hyannis 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 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 -' ` -P, -- ,�sa 7. � �+ dy F.E� '� .#�"it r «4m-_'• i '� "w �# ;v'C$ ' t., tl � .t v -,` I . # d mwni r p ' ' '�`rFY c �'"'"f "Ea' �" °4 "k A. , ' "!�f n If or `�" '� il:f.. "'C4 95 v '"M,r n a i. M'�VS'�"'� -m �_ �✓y, ,.- + € rIt4 4' i ' ; iH�l•� ��� PN ,�,:,` � -:, �,i i;�i ",� .� �s�qb '- y F. s .� °w"r��p"� l €�• r F �' � �i'"ri � p .y�T�' � . -0 �m Y �.r { 1 M1's far s inaiIP, .... s . Y plyyll'sx •,�.. kid" i YY.. I .,'*,. Y`i' _ '• 4' t_ Nk - S �. " ° r�` r r -� r 'kr"� it r �,�� 4 ���"Yw �fi� �,._ y ��"' �i�.✓, I a 3^" � ,.g_ 1 m r' ., ter,, Won A '..u� sq € itFk- ':: i 'dr ��4 ,�- a ` 5 * .r - 4 ' 641 � r/f 11 tit, I "EPA mu , . p m :+ n� ' f c s c _ 50 a ` V ,ti " rmaf Sys, : 7 uP m - s.:'. - �,e d p t' m fie:_-�r. 0. ,: �.` '+� m•rrn w�. ,• _ ;� a� 1� it il r� � r�� � '��"'�€ y�#� { - `� nm:.... 1 . �. a 'm •vgWMxd *,�gauc , 1 . W. ', u = , 46. ^w Y w Y ey: a c.a°�''�,d:� � t .4 •� M� w Y r m s .� }''�C, e "m ,_6r< , � F Ain IS w s 9 t Commonwealth of Massachusetts .�r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for`1loluntary Assessments 256 OAKLAND RD Pi al em)Acid es`a` GRISE Owner Owner's Name information is !��r.lUl�llS �-4u!�fir:!o MA 01 Ii1 every page. Cttylfown 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: A, General Information 4^Jh��fi:.!tna nt:! forms the computer, r,use 1. Inspector: only the tab key io move youf DOUGLAS A BROWN cursor-do not __ Name of Inspector key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address QI=1Y I ERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 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 cir^P6sal sysiCrs. I am a DAP appro-ved systems inspector p�-w-u t tc Sectto-rr t5.340r of Title 5(310 CMR 15.000).The system: 14� Passes I=1 Conditionally Passes I-1 Fails ❑ Needs Further Evaluation by the Local Approving Authority ii/21/ii Inspector's Wature 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 systein.Qwner,shaU subrra 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 tinder 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ( iii f cornmonweam of MassachuseUs Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 OAKLAND RD Dr,.perty Addrers GRISE Owner Owner's Name information is req-„fredfor. HYANNIS MA. 02601. 11121111 every page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) inspection Summary: Check A,B,C,D or E I arrays 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: SYSTEM APPEARS TO BE ORIGINAL FROM 1980 AND APPEARS TO HAVE BEEN WELL ALAI T AINED. THE PIT 1.4 FRONT YARD AS OPENED- HAS���'DSABLE SPACE LEFT NO SIGNS OF FAILURE AT THIS TIME,THE SYSTEM IS OLD HOWEVER AND FUTURE PERFORMANCE CAN NOT BE PREDICTED 113) System Condi ity 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 v�ifl'nrcza inanQntinn if tha=_iatinn tank-is raninn-A-f,,pith n rr-rnnivinn- ggnt^tanln ac anrrrnr<trt 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): l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 0 25 6 OAKLAND RD Prcpzrty GRISE Owner Owner's Name information is re uiredfor HYANNIS MA 02601 11121111 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to biio`iier5 or abstrueted pipe(g)6F a'ue to F5�6ken, setifed of uff V6n dig libut' a box Sys e�ri visit pass inspection if(with approval of Board of Health): broken cipe(s)are replaced n Y n N! 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 Sate in -'r, W fin. ❑ brokenpipe(s)are re laced L ,p ❑ Y ❑ N ❑ ND(Explain below): ❑ 6b§t!'uction'is removed � - ❑ Y fV - L� ❑ N!D(Ezpiain bet6w`: 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. 1. System will pass unless Board of Health determines in accordance with 310 CHAR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: i_I C;esspool or privy is wtnin bu feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 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 ®°" 256 OAKLAND RD GRISE Owner Owner's Name information is HYANNIS required for MA 02601 11/21/11 every page. City/Town State Zip Code Date of Inspection B. Certification (cons.) 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 eater 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 ❑ 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's*. Method used to determine distance: ==This system passes if the well water analysis, performed at a DEP certified'laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No 17 Backup of sewage into facility or system component due to overloaded or — — clogged SAS or cesspooi ❑ ® 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 T!e 5�_�-!En_,-.on Form: 3�._Qe r - :- -Pace 4 d. commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 OAKLAND RD GRISE Owner Owner's Name information is required for HYANNIS MA 02601 11/21/11 every page. City/Town State Zip Code Date of Inspection S. Certification (cons.) 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. n Any portion of cesspool or privy is within 100 feet of a surface water supply or i^buiary is a surface`:vaier supniy. r ❑ ® 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 is_e:i a Private water: ' ""i%rocii---t ::=ac-�c-aNiauie water " - — �YN s" yiia::i� a::aiy_ia. g`a a > 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 s%,E-_torn is n r,z-sn-nl senfin_e-n fanilifv wnfh q rlF-inn f n A,.-f 9nnnnnr4,_ 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) Ld-ren Sy-7—: a. iv uc ssL•I:SCR2CIC4d a iarcc$ybi�Itf ihe:iymiemul eei_�i Serve a liaviliiy vviih 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—I W PA)or a mapped Zone 11 of a public water supply well -c ;3.a.".e..anev ere.'.'. __ `�.are N::a�.;�n....: a :: :n-tZs-L..:�:: `fka 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 CM 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts N�91 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 OAKLAND RD Property Address GRISE Owner Owner's Name information is iic- !!Y^!1!LIS MA WPM 11191/11 every page. Crty/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 an of the system components Y Y onents pumped out i P P p n 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? ❑ ❑, 'rda:the site inspected for signs of break cut r ❑ ® 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, dimension s: 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 g p 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 Ci is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)) D. System Information FlvvJ:,sU!!:dl G!•J!l.�.. Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f �L\ Commonwealth of Massachusetts pTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � '< 256 OAKLAND RD GRISE Owner Owner's Name information is required for HYANNIS MA 02601 11/21/11 every page. City/Town State Ip Code Date of Inspection D. System Information Descrlption: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A SEPTIC TANK D-BOX AND 2 LEACH PITS Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): SEE BELOW Detail: 20097-------193 2010----204 Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENT_ Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 Civ7R i5.203): 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 OAKLAND RD ?.,,pert, ddra_z GRISE Owner Owner's Name information is required for HYANNIS MA 02601 11/21/11 eve page. C frown every p g � State Zip Code Date of Inspection D. System information (cons.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: OWNER PUMPED IN AUGUST OF 2011 1500 Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: 1500 AUGUST OF 2011 gallons How was quantity pumped determined? Reason for pumping: MAiNTENAidC,E Type of System: M Septic tank, distribution box, soil absorption system `. vin Jac 4GOs;,fo ll ❑ 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. 7 r)±har/rir-gr_.rih,=& t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 OAKLAND RD Drc-pc , dd __ GRISE Owner Owner's Name information is required for HYANNIS MA 02601 every page. City/Town 11/21/11 State Zip Code Date of Inspection D. System information (cont.) Approximate age of all components, date installed if known) and source of information: APPEAR TO BE ORIGINAL FROM AS-BUILT CARD Were sewage odors detected when arriving at the site? ❑ Yes ® No Buildlino Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) if tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 ACCORDING TO PUMPING RECIEPT Sludge depth: TRACE t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Dsposal System-Page 9 of 17 \ Commonwealth of Massachusetts Wiling Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 OAKLAND RD GRISE Owner Owner's Name information is required for HYANNIS MA 02601 11/21/11 every page. Cityrrown State Zip Code Date of Inspection D. System information (cons.) Septic Tank(cori.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness LIGHT Distance from too 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? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK WAS PUMPED IN AUGUST AND LOOKS CLEAN 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 bistance 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 15ins•09/08 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 OAKLAND RD �. pe GRISE Owner Owner's Name information is HYANNIS required for MA 02601 11/21/11 every page. City/Town State Zip Code Date of Inspection D. System information (cons.) 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 constr action: ❑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 t`•;r; „J; Ttie 5 0m_ial in_ '„,r,Fcm:^uGsu'a e Segraoe ;gal.^y-„cm•Pa de,I..,17.. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Asse ssments 256 OAKLAND RD GRISE Owner Owner's Name information is required for HYANNIS MA 02601 every page. Cityrrown Date of Inspection 11/21/11 State Zip Code D. system information (cons.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL NO SIGNS OF LEAKAGE/SLIGHT SCUM LAYER PROBABLY DUE TO AGE Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: PIT IN FRONT YARD WAS OPENED AND HAS 16"OF USABLE SPACE BELOW THE INVERT `MITI Nn fzlr;"jS nF Fa1I I fRF n4 n\!FR !nUr 'sins•09M Title 5 Offi'._nspe=i T FOF . v _;s'em Page 12 v{.7 \ Commonwealth of Massachusetts Title 5 Official c al Inspection p Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 OAKLAND RD GRISE ^^ Owner Owner's Name information is required for HYANNIS MA 02601 11/21/11 every page. City/Town State Zip Code Date of Inspection D. System information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ lear_hino galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): PIT IN FRONT YARD WAS OPENED AND HAS @ 16"OF USABLE SPACE BELOW THE INVERT VVI 1 r`i- NU UI- f AILUHt A 1 i Wt Ur lMjFLU I iUN. 1 HI }� At'F�;itv I U ct li-1ti 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth -of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 OAKLAND RD Prcperty ddre GRISE Owner Owner's Name information is FiYANNIS required for MA 02601 11/21/11 every 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.): i`_•li s••^,SYY"_, ..e` :ial L-5�•c:,� Fm;Sut,`a•:e Saw�oe_1;5ri0sa:S'y'ale�•Pa 14 of 17 C\ Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 OAKLAND RD Pr,j-_rt,,,,---_- GRISE ^r Owner Owner's Name information is required for HYANNJS MA 02601 11/21/11 every page. City/Town State Zip Code Date of Inspection D. System information (cont.) Sketch Of. Be age 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 . �5 r?!rF.ia• n_c n Forth:SL.t-SC"'_c=$a;1802 DW-Mzci S,SteM•Pane,F�or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 OAKLAND RD Pr_ erty add--_ GRISE Owner Owner's Name information is required for HYANNIS MA 02601 11/21/11 every page. City/Town State Zip Code Date of Inspection D. System Information (cone.) Site Exam: ® Check Slope ® Surface water ! ! Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 5 FT feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ut C_'.I'SFf.{prl i-AAfh lnrnl Rnnrrl of W,-nlfh-axnln n• . ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: TOOK ELEVATION AT BOTTOM OF PIT AND CARRIED IT OUT INTO ADJACENT WOODED AREA TO A DEPTH OF 5 FT BELOW BOTTOM OF PIT Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09,06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of V 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 OAKLAND RD GRISE Owner Owner's Name information is required for HYANNIS MA 02601 every page. C!tyrrown 1 State Zip Code Daatete o of f 11 Inspection E. Report Completeness Checklist inspection Summary:A, S, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater Ckafrh n{CPL ?nuP!�ECnl4Sal ntilCfPE 1 either r!rarafr nn naua 15 nr M nP.Inai in z nnrnfA rIF f .Luc 5CIc uil`S;J`sic�etiaoc L_ ___;G'y'5'2:Ti•P3aa 17v.1.7 . Assessing As-Built Cards f- Page 1 of I LOCATION SEWAGE PERMIT No. 0 VILLAGE 4 'laQ _ r7/ �IYJY/r I N S T A I.LER'S NAVE i ADDRESS GUILDER OR OWNER v tA- DATE PERMIT ISSUED OAT GOMPLiANCE ISSUE0 v /Y/0 U5 �° http://town.bamstable.ma.us/Assessin dis la .as ?ma ar=271129&se —1 g� P Y P� PP q— 11/17/2011 Y Capewide Enterprises, LLC Invoice J.P. Macomber& Son 153 Commercial Street Date Invoice No. Mashpee, MA 02649 8/12/2011 15172 Name Susan Grise PO Box 1297 Centerville,MA 02632 Job No. Terms 10019 Due on receipt Quantity Description Rate Amount I Septic pumping, 1500 gallon tank at 256 Oakland Rd,Hyannis 295.00 295.00 Thank you for your business! Total $295.00 A finance charge of 1.5%per month will be charged to any outstanding balances that are not paid in full according the payment terms above. Payments/Credits $-295.00 Balance Due $0.00 Phone# Fax# E-mail Web Site LO CAT 10�� SEWAGE PERMIT 930. O�/!G�✓�y.0 'oeO VILLAGE 67 ll� �Y�iyiyis INSTA LLER'S NA III E & ADDRESS 0 U I L 0 E R OR OWNER � c1/ Qlf;,: s /4 41le 'l-11 eilJ� DATE PERMIT ISSUED 4/ z.2- Fo DAT E COLIPLIANCE ISSUED Z �. �� �� '� � . � a � �� N - 1 No7y..-?6.�. FFi& .0................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH . ..1...... oF... .R�N. ------------------------------------ Appliratiun for Diapag al Work Tunitrurtiun ramit made for a Permit to Construct or Repair an Individual Sewage Application ><s hereby a e ( ) p ( ) 5 ge Disposal S stein at . ...........!--�------ �----------------•-- Location-Address,, or Lot No. .. � ------------------------------------•-•------ -------------------------------•-•----.-•- Owner . ....................................Address - = . - = Installed Address Type of Building Size Lot_:!l_�3/_____.Sq. feet U Dwelling—No. of Bedrooms_ c�-_..•-__-__-••-________Expansion Attic ( ) Garbage Grinder (-fle) Other—Type of Building __t�ih/ MNo. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/5-0-?--gallons Length................ Width................ Diameter................ Depth-_-•___-__--__-- x Disposal Trench—No. .................... Width..(................ Total Length............ Total leaching area ..........._..._sq. ft. Seepage Pit No---------I-__-_:__- Diameter../!............ Depth below inlet_...&........... Total leaching area.4VIV._...sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed ......................................... Datell//6-`?.rf................. aTest Pit No. 1_.41-_-----minutes per inch Depth of Test Pit..1.2 ......... Depth to ground water_ti --- Test Pit No. 2_4:.!-_....minutes per inch Depth of Test Pit ht I............ Depth to ground water_ .......... r O Description of Soil..... .......e,_-f- Sk)311.9----------2- -----•--- ---------•--•-----------------•----- V ----•-••-•--•--•••••-•--•-•--•-•-----••--••••--•••••••-•••••----•-••-----•-•••••---••...................••-••-••••-••-••-••.....--••••--••••...----•--•----............................................. -•--•---•---•-------------------------------•---•----------------..----.-------------•----•-------------•-----------------------------•--------•---•-•---•--------------•-••-• ......................... V Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ......................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I i: L p 5 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. Signed D � // Application Approved By_, , a :. -..............:...................... ...---.. Da... -a e --•-•--- ,Date Application Disapproved for the following reasons----------------------------------•---------------------•--------------------------------------•---•••-•--••-••-- ....•--••...-•••-•-•--•-•-----••••----•--..........•-•--••----•--•••••••••-------••--........•---•••--------•-•--•-----•--••••-••-••---••---•-: :--- -------Date PermitNo......................................................... Issued..........•-••--•---••......•-••---•----..Date------. Date �7 � r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF. ., l-v w . ................ 7.�`�4. &-Sr4-r'� .L'...---------......_-... ._.:......... - ppliration for Uiipnsa,l Works Tontitrnrtinn rrmi# lication is hereby made for a Permit to Construct � or Repair an Individual Sewa a Dis osal �PP Y ) P C ) g p" System at• i,' P-D ................ _......._... --------• ...................--............................................................................. t A or Lot No. Crfi S `. �A.r Loc n s W SAX-5 %��'1 Address _____________ - _........- ----------•----------- A•dd-•-•res-•s--•-•-•......•-------------------------•-••- s ter Type of Building — Size Lot.......I................... feet Dwelling—No. of Bedroom ...............Expansion Attic ( ) Garbage Grinder a Other—Type of Building ft� _.e t"l1 o. of persons.................._.__.. ( ) Cafeteria ( ) .::. Showers — d Other fixtures ------------------------------------------------------I•-•-•-•---------...--=--------------------------------------------- .. W Design Flow_________________________________ gallons per person per day. Total daily flow............................................gallons. / dl! WSeptic Tank—Liquid capacity............gallons Length................ Width-.............. Diameter................ Depth................ x Disposal Trench—No...........:........ Width__ _....._._._____.Total Length........ ..I...... Total leaching area_____ _ sq. ft. Seepage Pit No---------/-_______-- Diameter---/9------------ Depth below inlet.... ........... Total leaching area. a��....sq. ft. Z Other Distribution box ( ) Dosing tank W Percolation Test Results Performed b ._•A.___' (1 t + .......................... ._ Date�� _ O_ 9 Y l� Test Pit No. 1__Q' "V_._._.minutes per inch Depth of Test Pit__1`t ......... Depth to ground water_ti4N �.__._.._.. �,*4+v C(z, Test Pit No. 2_.,{_�......nrlriutes per inch Depth of Test Pit-4 ............ Depth to ground water........................ P4 ............................................................... -•--•-••--•-•------------••-•--•-••......••-••.....---•--•... _ 0 Description of Soil.....0.-"--2........ ........z <��, �=5��/LSt .........SAYVb............... V .....•-•••••••-•••-•••-....-•------•-•---•-•--------••---. W UNature of Repairs or Alterations—Answer when applicable................................................................................................ --------•-•------------------•------------------.....-----------------------------------------------------.....--••--•--•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of t'1T/'1:�'•T 5 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. Signe(Z---- ..................... DatV t�� .� _ Application Approved By____ ___.. Application Disapproved for the following reasons: ------------------•--------------------..-•---•......---•-----•---------•----••••...•-•--•'- -L .........-•---•-----•------------•--------••-•----•---------•---------•----------•------------------------------------------------------------- }, . Date PermitNo...........................................-=----------- Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........OF ....:..... �. �rrfifira; �r THl� IS00 C at the Individual Sewage Disposal System constructed (L/or Repaired ( ) b . Installer at....�.-* ---------- has Isee fnstaIled in acco �i'I � ovts163Ts�af TI`IZ&i�@444 tife Sanitary C* fde in tile' application for Disposal Works Construction Permit Yro.__ ..___ _''................ dated__..._____.....______-----------_.......s:..... THE ISSUANCE OF THIS ,CERTIFICATE S O716 ONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATEInspector..................................................................=.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH "�.W.N.......................OF :J )1v � L ._....................... FEE.. k. t11It�1� r pan ion amit �� � Permissionis hereby granted........----•�---...--�•--------------------�----------.:.-----............................................................................. to Construct ( ,)-pr Repair ( ) an Individual Sewage Disposal System at No... t� Cod" _X$e-------cw zzS►Tv • 25, --- -str�� � as shown on the application for Disposal Works Construction Permit No..................... Dated.........................._.._.._._....... r ---------------------------- DATE......................................................................... x, FORM 1255 HOBBS & WARREN, INC., PUBLISHERS wl . - /F,.E/7F/ER TNE'S�PTi� Al OR. z NIIVG Pi r_.4.RE /"IoRE' TNiq.J� C E Ao k.4 lam_E, 4 24"OY.4 M E T.�R CONE 'c ?'� O tiER = - '` ``' ';�,�'�.�-SJ•/.s!L L BE' %9�E7CCv i�T �O G/�A O`E./�,>✓'EiY7`Ri�1 CONCRETE r j�EAl/�/ CA ST /?O/Y CO l/Ei? Sf/AG L _DE USEL? colleRS M P/TCN , IN `-�B E _ j CO477 2 ` ACA L L -I L/QlJ/O LEYEL d: 4"CAST /. O •a. .�- 1 2 LAYER IRO-N P/PE _ GAL. o no w o� Q M I N. 8P/TCII 4 0 I , 0ni4 PEm �T. S�PT/C- T.4 NK w D I S T• _ {A d3iA 5 HF0 STiJNE y r: _ v u e e oEFFECT7✓E °r' ° m " n 3/4.f v:. o f.:.•r1_:,, : �•. p.+:,a DEPTH ° o o • d o�o WA5NED STONE_ p g5. ° s Joe o _o o e e e I vERA. fir.E IMVeAT e l-EVAT/®NS o d o eo0 0 ' e o 0 o e � e °�o P/7 OR EQ,V/V /Nd�ERT AT B[//LA//VG 9 G. FT, 6 fr D/- M. -� �y �yt /NLET SEP7"/C TANK 9�.n FT �d_ FT. O/fllyl. �, C SEE TABLLAT/ONE OUTLET.SEPT/C _rAW< 4 FT. _ /NLET UISTR//9UT/ON BOX 9` OFT. GROUND JV,4-rER TABLE OUTLETD/STR/.BUT/U/d ®OX 9 3 .� F7 SECT/Q.N OF JULI-EACHI"e PIT �� 6��l®li/ ®ES/GN �'fdI Z'�R/.®l s FT. �. NUMBER OF .&E�ROO,Vs-. 3 D/i�Ehl$%4N : C 4 FT' GARCAGEP/sPOs, I- uN/T._�_ SD/L jDT.4L EST/M.47TEO FLOH/ 3 3 O e�®IL 7"L GAL.�O.Q�' -SOIL. TEST / SO/L TEST#,2 AlUMBER OF . EACO/l/dGi f�/T.5 I` r`FLEY. GT l .0 �EL�J�_1� " �7 S/OE LEACH/NG PEI� ®/T d AATF aF So/L. 'TEST — / 2 - 2 RESULTS dN/TN.E SEED dY � !` BUTTON LEfgC///NG pER PIT 6_SQ• FT. c c7 /�j :C.'/G• PL`l4COLs�T/ON R�IT� I ` LESS M/N�/NLH TOTAL LEACHIIY& ARE✓q - 2--6:a6 SQ, FT. V I2COL.siY/ON R.�rTEE¢ � RESE VELEAC/d//VGAREA_a +a 6 _. �'�1N�/INCH —SQ. FT. - _ . _ r _ z., v- U 'BUN'KIS - �i�i _ p 110.22162 4 I;+ �'I S T 6Q �. _ E'L .. 9.O FL: S Z o 1. - 7/2,%9Ai/1/ Sr � FS5%ON,4t Eat/ _ - _ N®�/e061N(� d t�i�TER dr/�/COUNTEi�EO HYANM/3 ,/'9ASS 30 _YA.R/=90t/Tp1 MA ss' r :� - aJO'a /i/D .k GR � SHED Z OF l!� fiv 7. t}} IV � d�tl,V rp,t { t�h � - •y p t �,j 1•t `a 1'fJ.,t a y3A-A 1 4 yyrl D _ { �'b if$9 y Fpgrtl f!�},'.. ,, P t-. ,' - - � .. • ��,:/� � . r sty 4 Y _ S � to�• )! 20_ ➢.C� _ Y •, l��N{7�i� '•, gr.'FI _ .' / .. ; ,._ _ ..,y...- Ile 6 ; x » /000 rrq'L.. �n[� o f,,u: Lc, cA, Y(C y^ t7 ep + �•, `x 1 ' ; r } I x. v: T P.( Yr { J. ry 1 rw t ref rMft lfyYA�, 7 ;.t;ri ' YJ 6 -rf�' Ell 4 C 1 1 d6 4{ �r �' r11,�'ti i i }S�t� � d P C. t r,. �.��..__ •� t r r' +�? � S '. �' i a ply S.1 3 •k 1 i , �S /3 Z (� , - - ! ,` , J y. l� t 1 @':(%t!{} 4° �'� f; },; t -rJ t v , ) �{���••"r t , �•�o qzy �` t drr ! t •1 4t 1 � Ju��t fl`�4 "a ty( t, 3 ,�t ,�� rr' �• { G \013ERj. �9f�+}1S-07k-_�1 e p 5 fk,• ..,r t 1 af; .:,� , P.. 'BUN 1KIS No.22162E 0 � l� 0 f y 4f F q0� G/ST [� Y,� rr' (I i } ', ' -,� `a • J , . Fs`(� �l•:�\ +l l 5 ,i, � 1 if LEGEND , ,lE {14tTING".SPOrT ELEVATION�� ®><4 CERTIFIED PLOT '` f:PL A.N ;E� S91NG ` CONTOUR ; 4-- - K-i. ,„­/ a ,`' P�of i'F� lJ L�\I'`�T=.1 0� �L�i_`_-'"',i�- 'r -•T=`--°- `-0'T�/ �-� ��/V G ��� S If '� F { SF9ED COPdT®UR 0.1 ?ROVED, BOARD OF 'HEALTH IN t LA.T E AGENT SCALE : DATE { s DREOGE- f._-AlG1NEERiNG CO 1Ne-1 Al CLIENT I CERTIFY THAT THE PROPOSItD., f a REGISTEREC�t ;'REGISTEREDI JOB No. .Z.q_0 .1__. BUILDING SHOWN ON THIS . P,LAFV CIVIL LAND CONFORMS TO THE ZONING LAW-j, ENGINEERS,' SURVEYOR DR. BY `A "t'J_;_. p ___R -__ S) — ARNSTA8LE , btASal OF 9 CH. BY ; 1 vr_ M?1!N 7T 12 MAIN JT. �M(j;. i MASS ' i S. , . ' HYANNIS MASS. 0F .Z- DATE REG. LAND SURVEYOR