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HomeMy WebLinkAbout0130 OLD CRAIGVILLE ROAD - Health 130 Old Craigville Beach Road _�_— ------ Hyannis - ----------------- A= 248-121 TOWN OF BARNSTABLE LOCATION_112 (�c 17'ai qvi Ile raxd SEWAGE# fia t o - D�J VILLAGE H n K ASSESSOR'S MAP&LOT u�e 1 INSTALLER'S NAME&PHONE NO. t rs-09 -7?s SEPTIC TANK CAPACITY 1000 LEACHING FACILITY.(type),.-n) y /� (size) 5 NO.OF BEDROOMS BUILDER OR OWNER Bifkukae- PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility o I ht Feet Private Water Supply well and Leaching Facility (If any wells exist y� on site or within 200 feet of leaching facility) 1 f a Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) n Feet Furnished b 4 DU w c� `'' � �,,� w `''' `^' � � o , � � e � � ,� r ,�. 1 , ' � �� � j. � t � Y l � S�� i i ` `�� TOWN OF BARNSTABLE 20052,0 $ L•'x.ATION 150 OLD CL1b&VILLA` PLOA-0 SEWAGE # VII.,LAGE.141-fawo� ASSESSOR'S MAP &LOT 4 `2 i t c�7-N INSTALLER'S NAME&PHONE NO.'hL,_Q 6-s1_C _(,502)27 S - E 6 C) SEPTIC TANK CAPACITY (T�- A--l.-l.CK a LEACHING FACILITY: (type) L.;A('.1.d N& tit r (size) x NO.OF BEDROOMS_ _ BUII.,DER OR WNE NdI' ��►eeL PERMTTDATE: ' 21 Qe COMPLIANCE DATE. Separation Distance Between the: i Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 2 fi Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist } Feet within 300 feet of leac 'ng facili Furnished by 4 7 i �-Q O ,LV 47 p co D < LA "^ < l ADDRESS:j rl4NER'S NAME: 5/7�l%e SEWAGE PERMIT NO. : NEW: REPAIR: DATE ISSUED: 3/cO/ - DATE INSTALLED: INSTALLER'S NAME: C.:Ac��Nrl �j oray✓ � INSTALLATION .OF: 1" '—rArl k 6A WATER TABLE: FINAL INSPECTION BY: DRAWING OF INSTALLATION ON REVERSE SIDE: i' �— i� !� .�� s es�, ,.----� 0 L} -o�� A / P�� �� � w�- _��� �,.���� � No.� � Fee CT� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliLation for Disposal �&pstrm Construrtiun 3permit Application for a Permit to Construct( ) Repair(/o�pgrade( ) Abandon( ) f!�Pomplete System �dividual Components Location Addres o Lot No., Owner's Name Address,and Tel.No.S o,:57- /3a o C�•u<yvlda r°� tf.��ti.:,®`s ,�'w6�o-- �.1:;.�/�rGg. Assessor's Map/Parcel d f✓y�,�;y rT ,r G crr'� Installer's Name,Address,and Tel.No.,6'04P- »y-?d'�S Designer's Name,Address,and Tel. 07e--- �r</ �-!Qe'=/� C'frde C'e>:✓ Self<G ,e�vws� coop ,�����eEes%�9 Type of Building: Dwelling No.of Bedrooms Lot Size /7, sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) '� gpd Design flow provided y.S',f gpd Plan Date /��lcf 7 Number of sheets / Revision Date Title ✓/ /� 3 Sipe `'/a Size of Septic Tank Type of S.A.S. G'lr��afrS Description of Soil Nature of Repairs or Alterations(Answer when applicable) or �el� ifse� ,EJa�G � Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date / Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �( 5 6 Date Issued r^- No. I� r Fee /QV R THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4001, PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes JtJYIcatlOn fD,,PisposAY *pstrm Construction Vermit Application for a Permit to Construct( ) Repair vlUpgrade( ) Abandon( ) -•Complete System Eiln`dividual Components Location Address o•Lot No., Owner's Name Add ess,and Tel. /,ja O/ ��4�y'vil� ✓r� ,fy" f-5-^" �j-ti�Pr ��r�o� Assessor's Map/Parcel Installer's Name,Address,and Tel.No.fv� 77s'--ZJ�14-' . Designer's Name,Address,and Tel.No. �ljl ..��osf/� C'�F/e �"va� 6rA'f.G. 5 ,l�otiq �aOoe �CvysSsPfii'hq 7 v Type of Building: Dwelling No.of Bedrooms Lot Size /7, 3 y sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow(min.required) 3 3© gpd Design flow provided �S'.5— gpd ' a Plan Date /��/��7 Number of sheets / Revision Date ` Title Z f/e Size of Septic Tank /moo Type of S.A.S. S ,Description of Soil ,M Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: k The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by ( Date p Application Disapproved by Date for the following reasons Permit No. Date Issued 31W1V ,THE COMMONWEALTH OF MASSACHUSETTS f` BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(k-�' Upgraded( ) j Abandoned( )by � at /-5//"11—;;has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.,�V�&`056ated Installer , � Designer #bedrooms Approved design flo�Ion �,/�S� gpd The issuance of this pe it shall not be construed as a guarantee that the system wiDh t as desi ed. Date ) 1 'Y Inspector � v < -------------------------------------------------------------------------------------------------------------------- lit No. t '0��0 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction �Prmit Permission is hereby granted to Construct( ) Repair( fi� Upgrade( ) Abandon( ) System located at 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 m leted within three years of the date of this pe- it. --- Date Approved b "lI'® yam ®f Barnstable WE Regulatory Services, Th6 wgs F+ `Geiler,,D rector BA STABM Public Health'Division Thomas Mc Keau,"Directoir 200 Main!Stre6t,Hyalwis;MA,0160 Office: 508462 4644 Fax; 508-790-63,04 Iusta&r&]QDeg�ger fertifaeation Form 1➢ tet. *71 te Sewage]Permit#' Vol-e-. ora Assessor's Mzp\Pareel 2-"Az.I Doslgneir D rnl. jUMM J "( nstallere Address' A �j��i, Ig`f U : _ Addregs , 71R-WIUI/I:V� , N h9AW-Tr t"IU473 On /� u�i_.lfr, `s was issued a permit:to install a (date) septic system at ; j based on a.design f drawn by (address D, MIC kt UUL& f45 dated tzv. Z 2 _15 (design ;I certify that the septic system referenced above was installed.substantially according:to the design, which may include:minor sapproved.changes such as lateral relocation,'of the .distribution box and/or,septic lank. I.certify that„the .septic system referenced above was installed with., changes (i.e. greater than 10.' .lateral relocation.of the SAS or,any"vertical relocation of any,component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built,by designer to follow. OFy�, DANIELA. '(Installer'sSignature) ;�-:J MALA. .� C i II.. No 46502 .mow •� � � v �„ [UNA L ., -"(Designer's Sighature) (Affix Desi Here) PLEASE. RETURN TO BARNSTABLE PUBLIC HEALTH -]DIVISION. CERTMCATE OF COMPLIANCE CE WILL NOT $E ISSUEID UNTIL BOTH Tms Y oRm AND AS-BST CARD ARE � RECEWED BY THE BARNSTABLE PUBLIC-HEALTH IDIMION THANK YOU Q:Health/Septie/Designer.Certi#idation Form 3-26-04.doc CC Se Town,of B,n'st Nap- .ti. g,. &fie aax aaexat o�RegWatogy.Sa rvaces Fublie eafth.D'M� ��a Dante ua p. 200 Maiu Street,Hyanals MA 02601 '') Date Scheduled /Q k `/ Timo_ FeeJP'd, Soil Suitability Assessment �r S 0 Dispos I. Nerfarmed By: 1\� CGS � / Witnessed By: RM Location Address 130 0'4 Croa. V� `l� �. Owner's Narne 6 1^ _-"'-L � "N' Q►1.11 t.S Address Assessor's Map/Parcel: Z��/�Z/ Engine's Namr, U W c2 p e NEW CONSTR.UMOAI REPAIR /�'�/ Telephone# �UB, ��pp� ' 11�� Land Use: 1"fP�iod�„� a Slapcs(9b) Q��� Suzfacc3toues Distanccbfl-om: Open waterEody � ft Possible Wet Areaa(�/�t%��•fk DrIaldnSWat=Wcll Drainage Way l�j f ft Property Line - �../r ft Other, ft. SIC09TCH.,(Street name,dimensions of lot,exact locations of test holes&pero tests;locate watlands•I`n panx1n-dty to Izolea) elso y L II 16, Parent material(geologic) t� l Depth tq BetlrQcl� �' Depth-to Gronndwater: StandingWateria 1lole: Waepingf oM PltFflojr Estimated Seasonal High Groundwater Method Used: Depth Observed standing in obs.bole: _ __lgapth;,l_s?.5i1 xn9.ulas:- ltl, Depth to wceptngfmm side of obs.bole: ln, GroandwatarAdjwtmank Index Well# Rcading Date: Index VYe111pYe[ AdJ.fit tdr m .T_, dj.:L1[Y?ni)ClWntel'1 eYa1 Observation ]PERCOLAT1,0N TEST Hole# _ Depth ofFerc. —41 Time At6" Start Pre-soak Tlma @ � Time(9,14") End Fm-soak C Rate Mindla'rh SitrSultabiIltyAsscssrnettt; fiitvXassrct MCAFallod: Additional Tust(ngNeedcd(YIN) �y Original: Public health Dlvisloa Observation Holtz Data To Be Completed on Back-----�--- *911f Percolat!o* .test is to be eoudxaeted Wztbat 100' of wetland,you must first UOtIfY the. Ea rust able Couserv2do)a Division Rt least one(1)Week prior to begirniang. Q:15EPT'1C1PI RCF6RM.DOC DERP.OB8EI!V-XTFr, 0N'R0ILLq LOG ar # Dcptli ftom Soil Harizon Soli.Texture .Shcl Color Soil•. O t'hcr Surface(in.) , (IISD'A} (Niunsell) Mottling (Stiuuturc,Stones;BmIders, . fl i'toncy.°,l,'Cravcal ' a Drpthfrom BoilT•Torizon S'o`.ITexturc Soli Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stoncs,'Soulders. Consistmov.To Grave DEEP OIBSEI[V.4.'JCION ROLE L 0 G W Depthl'rorri Soilnorizon SeilTextura Soil Color Sail Other' Surface(in.) (JSDA) (Munsell) Mottling (Structuzo,Stoncs,Douldars.. Ca i tc o fl-gyv Depth from Soil Rod= SallTcxturc Boll Color SaII Other �* Surface(in.) (JSDA) (1Vlunse1l) NlottlIng (Structure,StoueeV Rouldars. ' Ca si tan b Flo 0a Ynstsrancaazaftmm'pn. Above 500year;flaadboundary l0___._ Yes ... Within 500 year'baundnry_ ltro 'Yes._ Within 100year flood boundary No, Y�errth�f 1'�'aftrraYy�!�9cc�srrin�-�'e��-rarss�a.�arit�Y • Does at least four feet of naturally oceurringpery as almixl oxist in all areas nbscrved throughout th6 area-proposed for the soil absorptibn systeml If not,What is the depth of hatarally occurring pervious materlall - - ��ai�ifrca�io�a x certify that on (dafe)Z itavepassnd fhe soil evaluator e9caminatlan approved ley the Depaitment of En'vir nmental FrOte0tIOn and thatathe above analysis was portorzned by me consistent With 'the required training,expertise and e:<perience described in�10 CMR 15.017. bafi Signature y p:�sl�r�lc�r�lzc�a�.>,n�ac f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old Craigville Rd. Property Address Michael Morgan Owner Owner's Name Informrequired Is H annis MA 02601 7-8-13 required for every _ 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 ng out forms `�LLquNlunpf��� on the computer, ``\��� �I OF M4S ri,��� �� use onlythe tab . Inspector: ����'.. 'E 1 key to move your use the return aa Ica v.vcca a Y ✓ Z r• 1 R�C G , ke Name of Inspector ;v Y• Capewide Enterprises,LLC _ S Company Name • Tlf `'� 153 Commercial St. 'o,F S i N S?��� Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 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 7-8-13 1 actor'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. t5ko-3M3 Title 5 O i"In -SubeLaface SZ/OWL�alaern•P�age 1 of 17 I•'d e9Z:90£6 60 Ins Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '~ 130 Old Craigville Rd. Property Address Michael Morgan Owner owner's Name information Is required for every Hyannis MA 02601 7-8-13 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 16.304 exist Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. 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 exfiltratlon 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•3113 Title 5 Official 4apedion corm;SuOerafaCe Sewage Disposal System•Page 2 of 17 d e n Z 9Z•80�1601 f commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old.Craigville Rd. Property Address Michael Morgan Owner Owner's Name information is required for every Hyannis MA 02601 7-5-13 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 pumpsialarms are repaired. B) System Conditionally Passes(cunt.): ❑ 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 c n 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. I. 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 Ins pection Form:Subsurface Sewage Disposal System•Pegs 3 of 17 £'d e9Z:90£160 Inf "t Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old Craigville Rd. Property Address Michael Morgan Owner Owners Name information is required for every Hyannis MA 02601 7-8-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) 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 Cl ED Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6"below invert or available volume is less than day flow ��T t51re•3113 Idle 5 Ol6del 4 apec6oa Form:Subsurface Sewage Disposal System•Pop 4 of 17 t,'d eLZ:80£1 601nf % Commonwealth of Massachusetts I Wk Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old Crai ville Rd. t Toperty AOQreSS Michael Morgan Owner Owner's Name information is required for every Hyannis , MA 02601 7-8-13 page. CitylTown State Zip Code Date of frts ion pect B. Certification (cont.) Yes No E ® Required pumping more than 4 times in the lust year wordue 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 curbaao 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:design flow To be considered a large system the system of 10,000 gpd to 15,000 gpd. must serve a facllitDr with a 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 su I the system is located in a nitrogen sensitive area(Interim Wellhead Prop Area—IWPA)or a mapped Zone I I of a public water supply well tet on If you have answered "yes"to any question in Section E the system is considered a significant 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. 15ins.3/'13 TUfs 5 Official inspection Forth:syNUface Sewage Dispasel System-pa8a 5 of 17 i 9-d eLZ:90 E 6 601nf /I e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old.Craigville Rd. Property Address Michael Morgan Owner Owners Name information is required for every Hyannis MA 02601 7-8-13 page. City/Town State Zip Code Dale of Inspection C. Checklist Check if the following have been done.You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS,located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 15ins-3113 Title 5 Official Insp ection Form:Subsurface Sewage Disposal system-Pego 6 of 17 9-d eL7,:80 E 6 60 Inf t\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Foam-Not for Voluntary Assessments 130 Old Craigville Rd. Property Address Michael Morgan Owner Owner's Name information is required for every Hyannis MA 02601 7-8-13 page. Cdyr town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.tank D Box and pit. Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2011-24,000Gals2012-20,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day NO) 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 Otficlal tnspedicn Farm:Subsurface Sewage Disposal System-Papa 7 of 17 L-d e8Z:80£L 601nf Commonwealth of Massachusetts Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old Crai ville Rd. Property Address Michael Morgan Owner information is Owner's Name required for every Hyannis MA 02601 7-8-13 page. Cdyl1"own State Zip Code Gate of Inspection D. System Information (Cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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/Altemative 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 UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5hs•3/43 Title S ofidel hU pedlon Form:Subwoew Sewage Disposal System•Pepe 8 of 17 s 8'd e8Z:90£L 60 inf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Old Craigville Rd. Property Address Michael Morgan Owner Owner's Name information is required for every Hyannis MA 02601 7-8-13 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: Tank D Box and Pit 1995-Permit#95-537/2008 Permit 2008-2051 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: feet , Material of construction: E concrete El metal ❑fiberglass ❑ polyethylene El other(explain) If tank is metal, list age: yeas Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal.Precast 1 Sludge depth: 154ns-3013 Title 5 Offidal Inspection Fomc Subsurface Sewage Disposal System-Page 9 of 17 6'd e8Z:80 El 601nf Commonwealth of Massachusetts ., Title 50 Official Inspection on Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 130 Old Craigiville Rd. Property Address Michael Morgan Owner Owner's Name information is required for every Hyannis MA 02601 7-8-13 page. CrtylTown State Zip Code Date of inspection D.. System Information (Cont.) Septic Tank (cunt.) Distance from top of sludgeto bottom of o 29" outlet tee or baffle Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8„ Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Asbuilt-Tape SludgeJudge 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 at working level. Tank and cover's at 1' below grade. Inlet baffle,outlet tee. Igo sign of leakacie or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete El 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: ------------ t5ins•3/'F3 Date Title 5 Orfidal Inspeom Form:Subsurface sewage Disposal system•Page 10 of 17 Ot'd e6Z:90£I. 601nf Commonwealth of Massachusetts Title 5 ffi i O c a Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old Craigville Rd. Property Address Michael Morgan Owner Ownees Name information is required for every Hyannis MA 02601 7-8-13 page. Citylrown State tip Code Date of Inspection D. System Information (cont.) Comments(an pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related tD 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 15ins•3r13 Title 5 Official Inspection Fam Subsurface Sewage Disposal System-Page 11 of 17 l 6'd e6Z:20 0 6 60 Inr Commonwealth of Massachusetts NEW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old Craigville Rd. Property Address Michael Morgan Owner Owners Name information is required for every Hyannis MA 02601 7-8-13 page. Citylrown State Zip Cade Date of Inspection D. System Information (cost.) 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.): D Box is 16"x16"-23" below grade. Box is clean and solid w/one line out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): "If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan,excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Zl'd e6Z:80 Cl 601nf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Old Craigville Rd. Property Address Michael Morgan Owner Owners Name information is Hyannis MA 02601 7-8-13 required for every page. Cityrrown state Zip Code Date of Inspection Q. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: El leaching galleries number: 9 ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovativelalternative system. Type/name o1 technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. precast pit. Pit at 35"below grade wlcover at 7.10" water in pit Stain line at 16"from bottom of pit. 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-3113 Title 5 Offrdel Inspection Form Subsurface Sewage Disposal System-Pepe 13 o117 £l'd e00:20 E l 601nr Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1.30 Old Craigville Rd, Property Address — Michael Morgan Owner Owner's Name information is Hyannis required for every MA 02601 7-8_93 page. clty/rown 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 t5im-3113 T IM 5 Olfl"Inspeetian Farm;Subsurface Sewage D*osel System.Page 1 a or 17 i�6'd e0£:80£l 60 Inf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Oki Craigville Rd. Property Address Michael Morgan Owner Owner's Name requir required is Hyannis MA 02601 7-8-13 required far every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Rl W,4Y LJ DEc4r - = 3 .2-�� k;� - _ 38 _, J O t55ns•3r13 Title 5 Olriaal tnspedion Form:Subsurface Sewage Disposal System-?age 15 of 17 9l,'d eOC:90`1, 601nf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old Craigville Rd. Property Address Michael Morgan Owner Owner's Name information is required for every Hyannis MA 02601 7-8-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Nd Estimated depth to high ground water. feet • 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: Past Report ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: WELL AIW 230/ZONE -D You must describe how you established the high ground water elevation: Past report 5-16-08-Auger Hole 14' No G.W.. Bottom of pit at 9'. Bottom of pit at 5'above Auger Hole. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 151r*-3r13 We 5 Official tnapectior.Forth:Subsurface Sewage Disposal System•Page 15 or 17 gt•d 8L0:20 0, 601nr Commonwealth of Massachusetts Title t e 5 Official Inspection Form a Subsurface Sewage,Disposal System Form -Not for Voluntary Assessments pf 130 Old Craigville Rd. Property Address Michael Morgan Owner owners Name information Is required for every Hyannis MA 02601 7-6-13 page. Cityfrown 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 We 5 Official Ins pection Form:Subsurface Sewage Disposal System•Pape 17 of 17 L[,d 8 6£:80£6 601nf I, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old Craigville Rd Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owner's Name information is required for Barnstable MA 02630 8-3-11 every 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: A. General Information When.filling out forms on the computer,use 1. Inspector: only the tab key to move your Darrell Stone cursor-do not Name of Inspector use the return —! key. Cape Cod Septic Inspection i c? Company Name , PO Box 1466 'F Company Address _ n Harwich MA - 102645 ----- n City/Town State Zip Code W 508-240-2500 S14995 Telephone Number License Number B. Certification i that I have personally inspected the sewage disposal system at this address and:that the I certify t p y p 9 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 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-3-11 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. L% I Title 5 Official Inspection Form:Subsurface a isposal system•Page 1 of 17 t5ins•11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Old Craigville Rd. Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owner's Name information is required for Barnstable MA 02630 8-3-11 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y. ❑ N ❑ ND(Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old Craigville Rd. Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owner's Name information is Barnstable MA 02630 8-3-11 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 y i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Old Craigville Rd. Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owner's Name information is Barnstable MA 02630 8-3-11 required for -every 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 El ® 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 k or clogged SAS or cesspool f ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•11N0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old CraigviIle Rd. Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owner's Name information is,required for Barnstable MA 02630 8-3-11 every page. Cityffown 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 t r tributary o a surface Ovate supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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•11/10 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 130 Old Craigville Rd. Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owners Name information is required for Barnstable MA 02630 8-3-11 every page. Cityfrown 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? ® 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): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 549 t5ins•11110 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 °< 130 Old Craigville Rd. Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owner's Name information is required for Barnstable MA 02630 8-3-11 every page. City/Town State Zip Code Date of Inspection . D. System Information Description: 4 Bedroom residential dwelling 0 Number of current residents: r Does residence have a garbage grinder? ElYes N No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 155.74 gpd Detail 2010-82,280 gallons 2009-31,416 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Da enown Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ .No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old Craigville Rd Hyannis, MA Property Address The Irene P. Kensten Trust owner Owners Name information is required for Barnstable MA 02630 8-3-11 every 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: unknown 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 I� ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 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 130 Old Craigville Rd. Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owner's Name information is required for Barnstable MA 02630 8-3-11 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1995 Per BoH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 19"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.): Apparent good condition Septic Tank(locate on site plan): Depth below grade: 13°feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon 3,r Sludge depth: t5ins•11/10 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 130 Old Craigville Rd. Hyannis MA Property Address The Irene P. Kensten Trust Owner Owner's Name information is Barnstable required for MA 02630 8-3-11 every page. CitylTown 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 29" Scum thickness 2" I Distance from top of scum to top of outlet tee or baffle 5„ Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Normal liquid level No sign of leakage SCH 40 outlet tee Recommended next maintenance pumping within 2 years Recommended maintenance pumping eve 2-3 years Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Foam:Sulmrface Sewage Disposal System•Page 10 of 17 ii Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Old Craigville Rd. Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owners Name information is Barnstable MA 02630 8-3-11 required for every 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.): II 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.): M *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Forth: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 130 Old Craigville Rd. Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owner's Name information is required for Barnstable MA 02630 8-3-11 every page. Cityfrown 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 1 011 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.): Grade to box 23" OK condition 1 Outlet Normal liquid level No sign of leakage No scum No sign of failure Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Old Craigville Rd. Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owner's Name information is required for Barnstable MA 02630 8-3-11 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of . vegetation, etc.): 1 (6'X6').pit with 2'stone Grade to pit 34" Cover 6" Bottom 109" Dry No sign 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-11/10 Title 5 Official Inspection Forth: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 w 130 OId Craigville Rd. Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owner's Name information is required for Barnstable MA 02630 8-3-11 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Old Craigville Rd. Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owner's Name information is Barnstable MA 02630 8-3-11 required for every page. Cityfrown 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 LUt I I t � I A S i 2 -b 2 3 3 7- ' o 4 33- 5 6 t5ins-11/10 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 130.Old Craigville Rd. Hyannis, MA Property Address The Irene P. Kensten Trust owner Owner's Name information is required for Barnstable MA 02630 8-3-11 every 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: >2 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: Test hole results from previous inspection ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Bottom of SAS 109" Bottom of Test hole 168" NWE Adjustment 2.9' Al W-230 Zone D 22.7' Separation >2.02' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 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 130 Old Craigville Rd. Hyannis, MA Property Address The Irene P. Kensten Trust Owner Owner's Name information is required for Barnstable MA 02630 8-3-11 every 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ;a t .4 i No. ���� Z�S Fee ADO r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Applicatton for Migont *_ vmem Con0tructtou Vermtt Application for a Permit to Construct(X Repair(/ Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. 13 Q O(> GIZAt"rt.cc Owner's Name,Address,and Tel.No. 1-o`-y 150MW I� f i NV—lF Assessor's Map/Parcel �gi�l Lo q ! / ��� '1310+y co 1CQAII V,cc r?" 1 + rvA Installer's Name,Address,and Tel.No. CS08 01 -Designer's Name,Address and Tel.No. 3 L UE-W ATEIRL 77T-2-600 &G-0 MAJ N 5T . 1,J Type of Building: ` l qn S — Dwelling No.of Bedrooms {; .r Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building 1��tTstll +nl&- No.of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow(min.required) / gpd Design flow provided / gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank I, 00n Type of S.A.S. Co'XCo' 1, A_yrAj(k p r7, Description of Soil Nature of Repairs or Alterations(Answer when applicable) P­LIP lQC p })/STAP/$L1A/ U,c by F. 7b Co eeOSS/&'j 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 b this Board of H P Y Signed / Date 5 Application Approved b)q Date S 2! 00- Application Disapproved by: Date for the following reasons Permit No. 2L00 g-- Z0 Date Issued " �� O Of} „ No. 20U�j 2(�S Fee �Qd _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ppli cation-for'Di!6ponl 6p!5tem Cottgtructiou Permit Application for a Permit to Construct(X Repair(X Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. 134 OLn, GRAQO•N 1l.t& O'IANnl15 Owner's Name,Address,and Tel.No. t o%`'! T3oNN l Ptnt�lE Assessors Map/,Parcel t.c N 7l912i - �r u Installer.'s Name,Address,and Tel.No. �508�^ —L6 Designer's Name,Address and Tel.No. 3t U+E WACE2 -775'-2600 em- Type of Building: - , ` (9�1 S ' S?' M D'wellingh No.of Bedrooms + Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building 4DWf)_L1Mt- No.of Persons Showers( ) Cafeteria( ) Other Fixtures ” Design Flow(min.required) gpd Design flow provided .1� gpd Plan Date Number of sheets Revision Date / Title Size of Septic Tank I oo() Type of S.A.S. (o`A Co' L€q 4(&JCc Pt7- ' Description.of Soil \ n Nature of Repairs or Alterations(Answer when applicable) )�P,0 0 F (D/STQ/B L/_/AhAI 6 a K D667•. 7'o Co atoss/0t l 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 Iba• _ Signed / Date 05 2/ Os Application Approved by G• Date Application Disapproved by: Date for the following reasons ' Permit,No. OLOO g— Z O S' Date Issued 0 05 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (V ) Upgraded ( ) Abandoned( )by td tii t i N kC CX_ at \ 3CJ�� C (R�/�LL F_ W NA 1 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 O 0,5- Z G S dated Installer Designer / #bedrooms y Approved design flow �^/ gpd The issuance of this permit shall not be construed as a guarantee that the system will fun�tion 7desi Date �' 2 �' 2 o o&_._ Inspector : . c -- ------------- No. ---- Z G CS�" 2 G S� Fee /0 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Di.5pont 6p,tem C•opgtructtou Permit Permission is hereby granted to Construct ( ) Repair ( �' ) Upgrade ( ) Abandon ( ) System located at 30 d L(� C \G,�/ 1. �-� ( A NA a1\S r _ and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this it. Date 2 1 -2 D Approved by F 24— m Complete items t,2,and 3.Also complete A Signs item 4 if Restricted Delivery is desired. ❑Agent o Print your name and address on the reverse X ❑Addressee so that we can return the card to you.. B. Received by(Printed Name) C.-Dat f Delivery 0 Attach this card to the back of the mailpiece, Ili I or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1? ❑ If YES,enter delivery address Wk.1 ❑No 130 CM Crb-&qv t,l asps n L S' m Q a�U 3. Service Type 'I ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 70D6 21,50 000&I1041119765 (transfer from service label) � � _ { PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 j I UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 I � • Sender: Please print your name, address, and ZIP+4 in this box • I \office forms\tbhealthlbls.doc I '^own of Barnstable Public Health Division 200 Main Street 1' Hyannis,MA 02601 ` I I III,"�fl�{III►,III,��,�I1,It,Ill,�,il„���1�111�„1f���+I�I�I I � I U.S. Postal ServiceTM C CEIomestic Mail,Only;No Insurance E v r, qee-ra-ided) -. - - aFo�,deIivery,informatior+,visit our wedsite at www.uspsxom® � 1 r pt _ - V PS F� o�rm 3-800,AuguM2—OC MSFe Reverse for Instructions Certified Mail Provides: 8 A mailing receipt r n A unique id6ntifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mails or Priority Mail®. a Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. n For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". n If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 Town of Barnstable Barnstable Regulatory Services Department rtment IRARNSrABLF- "" 1639. Public Health Division m ArFD"A0�s 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director. FAX; 508-790-6304 Thomas A.McKean,CHO June 10, 2008 Bonnie Finkle 130 Old Craigville Road Hyannis, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 130 Old Craigville Rd,Hyannis, MA was last inspected on May 16, 2008,by Brad J. White, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) duo to the following: Distribution box is corroded and needs to be replaced. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BO OF HEALTH cKean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 9785 Q:\SEPTIC\Letters Septic Inspection Failures\TEMPLATGI.doc 30W Copy r Commonwealth of-Massachusetts, Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessm nt - 'ii ' ,M 130 Old Crai ville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 every 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. Important:When filling out A. General Information. forms on the computer,use 1. Inspector: only the tab key, to move your Brad J. White cursor-do not Name of Inspector use the return key. Bluewater Company Name . 350 Main Street Company Address West-Yarmouth MA 02673 Cityrrown. State Zip Code (508)775-2800_ 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. TttinsI3 tion' was performed based on my training and experience in the proper function and maintenancelf on she sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15�340 af, Title 5(310 CMR 15.000).The system: .� ❑ Passes v? ® Conditionally Passes ❑ Falls ❑ Needs Fu on by the Local Approving Authority s TV)(/ 05/16/08 Inspector's Sig atur Date The syste spector 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 DER 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. BonnieFinkleT-S.doc•03/08 Title 5 Official'lnspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth oUMassachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form m Not for Voluntary Assessments 130 Old Craigville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 every 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: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved,by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: --�® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructedpipe(s) or due to a broken settled or uneven distribution box. System will r y pass ins (with approval of Board of Health): inspection if pp ❑ broken pipe(s) are replaced ❑ obstruction is removed BonnieFinkleT-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments - °M 130 Old Craigville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ® distribution box is leveled orreplaced ND Explain: -� Distribution box is corroded and needs to be replaced ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C Further Evaluation is Requited 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 j 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. El 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. BonnieFinkleT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form rm m( Subsurface Sewage Disposal System Forme Not for Voluntary Assessments G M , 130 Old Craigville Road - Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601, 05/16/08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma 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 El ® 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 El than '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or El ® obstructed pipe(s). Number of times pumped: El ® 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. BonnieFinkleT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of-Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments- ,M 130 Old Craigville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or.privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private.water supply well with no acceptable water quality analysis. [This s stem asses if the well water analysis, performed at a DEP certified i Y P Y � laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, . provided that no other failure criteria are triggered.,A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area IWPA) or a mapped Zone II of a public water supply well 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. BonnieFinkle-r-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form m Not for Voluntary Assessments ,M 130 Old Craigville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 every 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? ® 0 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)] k BonnieFinkleT-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 i Commonwealth of-Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form o Not-for Voluntary Assessments °M 130 Old Craigville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 _ every page. City/Town State Zip Code Date of Inspection D. System Information. Residential Flow Conditions: Number of bedrooms (design): N �°i Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Unknown Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes [g. No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d �(0,30 C PD 9 ( Y 9 (gP ))� 8 Hoo c�a•�; l 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: Last date of occupancy/use: Date Other(describe): BonnieFinkleT-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form m' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 130 Old Craigville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: System was pumped approx 2yrs ago 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: - A. ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool f ❑ Privy ❑ (NO) 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 l/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No BonnieFinkleTS.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System^Page 8 of 15 Commonwealth of-Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 130 Old Craigville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 every page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: ilb. 1-7 feet Material of construction: ❑ cast iron ® 40 PVC. ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer is in good condition. No evidence of leakage. Used camera to check all exterior piping Septic Tank(locate on site plan): 9„ 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: 8'x4'-10"x5' Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 29" 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measured BonnieFinkleT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 130 Old Craigville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees are in good condition. No evidence of leakage in or out of tank. Liquid level is, normal. Inlet has a baffle and outlet has a tee. Recommend servicing tank. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): BonnieFinkleT-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Old Crai9 ville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is.copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): ---up Distribution box is level, however box is corroded and needs to be replaced. Box is 24" below grade and has one outlet leaving it. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No �I Alarms in working order: ❑ Yes ❑ No BonnieFinkleT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form m Not for Voluntary Assessments ,M 130 Old Craigville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 every page. City/Town State Zip Code Date of Inspection Do System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 @ 6'x 6' ❑ 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.): —® Soil is dry. No signs of hydraulic failure. Vegetation is normal. No ponding. Leaching pit is 32" below grade. Cover has riser 8" below grade. Pit only had 3" of liquid in it. BonnieFinkleT-5.doc^03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 130 Old Craigville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): BonnieFinkleT-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 130 Old Craigville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 every page. CityrTown State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the buildinc. u, - a (3J� M r y FS _ I iJ e i —Cj '.._.._.__. ........_.. 2 0 Ire r I A,Z r 3a 32 r 35, AS , 3�' Q� s5 1 A14 - 3a BonnieFinkleT-5.doe•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of!Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 130 Old Craigville Road Property Address Bonnie Finkle Owner Owner's Name information is required for Hyannis MA 02601 05/16/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water Z Check cellar ® Shallow wells Estimated depth to high ground water: — 0 14+ 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: i ❑ Checked with local excavators, installers- (attach documentation) W ® Accessed USGS database -explain: —� Well Al W230/Zone D/Level 22.7'/Adjustment 2.9 x 12" = 34" You must describe how you established the high ground water elevation: Top of the leaching pit is at 32". Bottom of the leaching pit is at 9'-1"or 109". Augeered by hand 14' with no indication of groundwater. Augeered 168", bottom of the s.a.s. is at 109" minus the required adjustment of 34" leaves 25" of additional available space. BonnieFinkleT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 : ErJ : : -- _... _ F i I � I I � � Q 1n i. fs1r ; P V : � u i. d r L. - _ __ CA cJ to L : - - - -- 6 : t . .__.._. -- .. . s _ P : _ .. - — zi : Lk _c ; ........... - - - - I .. - - v : Town of Barnstable P� o regulatory Services =ARNSTABLE. : Thomas F. Geiler, Director MASS. 1639. ��� Public Health Division �prEO A Thomas.McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works. Construction.Permit If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. :1 P Q SE TIC\Disclaimer Private Septic[ns ections.DOC P P \ o No....... s2 ........3..6..JI THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABL.E Appliratioia for Div ooFal Work.6 Tomitrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: / ` ............................... ------------- ---'h --•---------------------------------•----------•------.._. Location-Address or Lot No. ...................... �d� F t y!r t-L�---------------------------- 3 0 1, Cr/3� v�`( - C/ ------ caner Address C.V�W/2r AX 6 �e tin e//� .tJ �7�- � ()c-iv,v�� �f S'. ��rtrevv�h •---------------------•------------------------------------•--- ------------------..•---• .......................... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms------------- --___--.__-______-__---_Expansion Attic ( ) Garbage Grinder aOther—Type of Building _.......................... No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ----------------------------------------------------------------------------------------------------------------------------------------------------- w Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter................ Depth-__--_______---- x Disposal Trench—No. .................... Width.................... Total Length----__-_.._..___.._. Total leaching area....................sq. ft. Seepage Pit No---------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �-' Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.-.___---__-___-_-_-_.-. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a ----•------------------------•-••--.._...•••--•-••••---••-•••--•---••••......-••••--•--••......--•-•......................................................... O Description of Soil..................................... x U ....------•-•---•-••---••-••----------••-••••---••-•-•••••-----•---•----------------•••--•-•••••--•-•-••-•-----------------•------••---•••------•--•---•-••••------------•-••--•-•......-••-••......•••. w U Nature of Repairs or Alterations—Answer when applicable._..T S.Ti3-GL------/Ppo.....�C3t_�_----Teq_N* ................ I�Q.•�' `t. t.�4.5/ Lj "�f '.... ...... ---------------------------------•---••••-•-•-............................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of.TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as been issued y e board of health. Signed -- -� '�-- 3—2 2- � " ,� Dare Application Approved B -------------- -==��G........f o- .......3.:.:.. Dace Application Disapproved for the following rea.ronr- ------------------- -------------------------------------------------------------------....................................... -------- ------------------------ --------------------------------------- .----- ---- -------------------------------------------------------------------......------..........----------- ---------.---------------------------- i re Permit No. ----- s ---------------------- Issued ..... ........ ....._a............. Dace V o No..................:� Fa$...............� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apphratiun for Diinpwml Works Tunutrnrtiun ramit Y Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal —System at ......1.,0 ©l-�...Cn✓��G-v��ze l �-/11_., 1 ----------- ......••--------•--•--•---•••-.........•-------------------- ................... ^d w,q&`/ Location-:\ddress or Lot No / ------`--------------_.._.....-----... --------------------------------------------L�------------------------------ •----••.......----QL.....--�i? . v,t c-----' � w ner Address �"n C A, L-' a/Uo✓� •,J r evN,s /�r/ r ' i9Amu v fJ� Installer Address Type of Building Size Lot............................Sq. feet DwellingNo. of Bedrooms--------------3----------------— __Expansion Attic ( ) Garbage Grinder ( e aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures _________________________________ w Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity_______-___gallons Length---------------- Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length------_----------- Total leaching area....................sq. ft. Seepage Pit No--------_----------- Diameter-------------------- Depth below inlet---------------..... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ f14 Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water........................ P+ ---------•-- •--•-----------------------•-----•----------•------....-•--•-------•-------------..........--••---•----•-------•---.....•...................... 0 Description of Soil------------------------------------------------------------•------•--••----•-•-----------•----••-•---------•-•••••--------•••---•-•---•----••••-•-----•-----------•_.. x U ._..•-•-•-•---•---••----•-•••---------•------•---•-••-------•--••--•-•••---•------••-------•---•--•••-•-•---•----------------------•--------•---•-------••••-•-•---•-•---------•------------•-------.... w UNature of Repairs or Alterations—Answer when applicable-----T�S-TALL_-_--/©off.. �y1........ �1 h/K ...S ...NF •------- -------- -------- -------------------- ----------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as been issued ,y ttthe board of health. �- 3-2 2-qs Signed .. - -- .. _._..._...............- ... -----------------. .................... �� Dare Application.Approved By ....,_ /'."u�..���'.- ------��t�c�_' '�--------------------------------------- --------3..�-,---- Dare Application Disapproved for the following reasons: ..._..._.__------------------------------------- --------------------- --------------------------------------------------------------- ._._.----- --- ---------------------------------- ..----- ...... .---- .---------- ...............------------ ...---......-----------------.......... Permit No. .S" S- 3 ? � ` �2 e ...................................................... Issued Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�ertiftrttte of (ILlumplian e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by.. L9w )2 e-' `-E-------- ani d ✓ -- ) - --- Insr.J ler / ----C`-------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...- s.. - _�----------- dated ------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WALL FUNCTION SATISFACTORY. DATE . -— - -- �- . _ - - - - Inspecto THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH S _ S3� TOWN OF BARNSTABLE00 No. -------------- FEE.--- ............... 11isposal Workii Tunutrurtiun rrrntit Permission is hereby granted I.tJ>2-... .... c�_v to Construct ( ) or Repair (X) an Individual Sewage Disposal System atNo. v D - f< _!_ _I/� C L...............�..--------•-------------------------•------------------._...----.. Street �. - 2 3 as shown on the application for Disposal Works Construction Permit No._-__�_____________ D�a ed.- �_-_—..... .............. Board of Health FORM 36508 HOBBS R WARREN.INC.,PUBLISHERS ALL, SHALL TE SYSTEM PROFILE MARK DS WITHC MAGNETIC TTAPE OR BE NOTES (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. PROVIDE MIN. 20" DIAM. WATERTIGHT 1. DATUM IS NAVD 88 to 28 ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE Route 2" PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS EXISTING \ TOP FOUND. EL. 47.2' FILTER FABRIC OVER STONE MINIMUM .75' OF COVER OVER PRECAST 3. MINIMUM PIPE PITCH TO BE 1�8" PER FOOT. s High o a 2% SLOPE REQUIRED OVER SYSTEM 46.8' c o NOTE: 2" MIN. WALL 4. DESIGN LOADING FOR ALL PROPOSED PRECAST School Q CO PRECAST H-10 THICKNESS REQUIRED BLOCKS OR UNITS TO BE AASHO H-ZQ RISERS (TYP.) PRECAST RISERS 2'0 4"OSCH40 PVC MORTAR ALL H-10 P' e tree O ` 6" MIN. SUMP PIPES LEVEL 1ST 2' COMPONENTS 5. PIPE JOINTS TO BE MADE WATERTIGHT. �ENDS 4' INV S EL. 42.80 4'12" MIN. INT. DIM. (TYP•) SIDES 43.80' j " o a o 0 0°o 0 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE n a ➢000a�o ° ° ° ° WITH i 10" "EXISTING TEE ° ° ° ° �0�� DqE�l ��O- ��0� 'o-.0-cc°cc EXISTING TEE *43.56' ° ° ° ° ° ° ° ° 1,000 GAL. 000000000000 WATERTEST O'BOX o ;�o�o�o�o ooaa000a �a�aooaoaa ;,.,.,000 310 CMR 15.000 (TITLE 5.) Locus SEPTIC TANK o 0 0 0 0 0�90000o°o°09 FOR LEVELNESS CV ;°o°°o°°o°o ;0'3'0'°000 �a�o�000ao °0 4 80' N PROPOSED D ° 43.06' 42.89' ° ° 7 THIS PLAN IS FOR ROP SED WORK ONLY AN ° 0• NOT TO BE USED FOR LOT LINE STAKING OR ANY a - OTHER PURPOSE. 3/4 1-1/2" DOUBLE WASHED STONE 4' MIN. H 20 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. 8, PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. ALL AROUND PRECAST STRUCTURES (3) UNITS REQUIRED o 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 33.5' X 12.83' 9. COMPONENTS NOT TO BE BACKFILLED OR COMPACTION. (15.221 [2]) o CONCEALED WITHOUT INSPECTION BY BOARD OF TobeY HEALTH AND PERMISSION OBTAINED FROM BOARD p� OF HEALTH. 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP 34.8' BOTTOM TH-1 CALLING DIGSAFE (1-888-344-7233) AND (2.3% SLOPE) ( 1 % SLOPE) NO GROUNDWATER FOUND VERIFYING THE LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF SCALE 1"=2000'f LEACHING WORK. FOUNDATION-EXISTING SEPTIC TANK 22' D' BOX 11 , FACILITY 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL ASSESSORS MAP 248 PARCEL 121 BE REMOVED BENEATH AND 5' AROUND THE LOCUS IS WITHIN FEMA FLOOD ZONE X *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL PROPOSED LEACHING FACILITY. (AREA OF MINIMAL FLOOD HAZARD) AS UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM 12. EXISTING LEACHING FACILITY SHALL BE PUMPED SHOWN ON COMMUNITY PANEL #25001 C0564J AND REMOVED OR PUMPED AND FILLED WITH CLEAN DATED 7/16/2014 LEGEND **INSTALLER SHALL CONFIRM MINIMUM SEPTIC SAND. 99- EXISTING CONTOUR TANK SIZE AT 1000 GALLONS AND ITS SUITABILITY SITE IS LOCATED WITHIN A ZONE II FOR RE-USE. REPLACE WITH 1500 GALLON X 99•1 EXIST. SPOT ELEV. SEPTIC TANK APPROPRIATE TO SITE CONDITIONS IF NOT SUITABLE SYSTEM DESIGN: -[99]- PROPOSED CONTOUR [98.4] PROPOSED SPOT EL. TH1 GARBAGE DISPOSER IS NOT ALLOWED TEST HOLE EXISTING 3 BEDROOM DWELLING 27-, SLOPE OF GROUND DESIGN FLOW: 3 BEDROOMS © 110 GPD = 330 GPD LOT 3 UTILITY POLE USE A 330 GPD DESIGN FLOW �qlFIRE HYDRANT � _ _ ---_ _,__ SEPTIC. TANK: 330 GPD `(2) _ 660 NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING o **RE-USE EXISTING 1000 GAL. SEPTIC TANK �9 LEACHING: TEST HOLE LOGS SIDES: 2(33.5 + 12.83 2 .74 = 137 GPD MAP 248 \ o ( ) ( ) ENGINEER: CRAIG J. FERRARI, SE #13871 Y� PARCEL 121 PAVED BOTTOM 33.5 x 12.83 (.74) = 318 GPD 0 11,639 S.F. DRIVE WITNESS: DON DESMARAIS, RS \ TOTAL: 615 S.F. 455 GPD 12 18 17 DATE. / / � � USE (3) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) PERC. RATE _ < 2 MIN/INCH WITH 4' STONE ALL AROUND �8 CLASS I SOILS P# 15557 EXISTING + °� ELEV. GRAVEL DWELLING p'° 46.8' 001 47.2' DRIVE TOF = 47.2 / DECK l' �Q \ APPROVED DATE BOARD OF HEALTH MA A - A TH1 LS LS 6» 10YR 3/2 8» 10YR 3/2 �, ��,\ 9 ' s, TITLE 5 SITE PLAN o OF B B LS Ls �� ° ��6 �� 130 OLD CRAIGVILLE ROAD 180' 1 OYR 4/6 45.3' 24" 10YR 4/6 45 2' 44 ,,'' HYANNIS, MA ' C1 C1 % PREPARED FOR MCS & MCS & GRAVEL GRAVEL LOT 5 KUBER BINDUKAR BENCHMARK: 10YR 7/3 10YR 7/3 CORNER Q� I 60" 41.8' 42" 43.7' BULKHEAD= DATE: DECEMBER 18, 2017 PERcE 46.2' NAVD88 / �_F_` of REV: FEBRUARY 28, 2018 (DESIGN FLOW) �-(N qS v4SN 0 Mgss �� 9C. C2 C2 qI o DANIEL �Gs DANIELA. y�� g A. MS MS o OJALA � OJALA off 508-362-4541 " CIVIL No.40980 fax 508-362-9880 10YR 7/4 10YR 7/4 �No.46502 downcape.com STE��� � (q FESS� oq ,0 SUR\'- down cape om lfteering loc. , tONAL 3 144 34.8' 144" 35.2' civil engineers--_._ land surveyors NO GROUNDWATER ENCOUNTERED Scale: 1"= 20' 2lf-uK f l �1 j y t / 939 Main Street ( Rte 6A) LIC E L� � 1 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 LI l% # ' //-`t50 17-450 CC SEPTIC-BINDUKAR.DWG