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HomeMy WebLinkAbout0047 OLD STRAWBERRY HILL ROAD - Health 47 Old Strawberry Hill Rd. Hyannis A = 249 113 o o � o w a a o a A C Commonwealth of Massachusetts ��19-tt3 ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is ✓Hyannis Ma 02601 3/25/2021 required for 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:When A. Inspector Information cam*` If 5a o19 filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane � Company Address Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com, S14522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Ap73/25/2021 ILIority 4. ❑ Fails Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �n Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis annis Ma 02601 3/25/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 47 Old Strawberry Hill Rd Hyannis is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and a 3 lateral leach field. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Old Strawberry Hill Road v Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is Hyannis Ma 02601 3/25/2021 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool i ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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. 5) Large Systems: To be considered a large system the system must serve a facility with a .design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form (- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts +� Title 5 Official Inspection Form . f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the 1/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: system installed 12/2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Joints in good condition, no leakage, vented through roof. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" 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 10" How were dimensions determined? Opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): Distribution box was video inspected and found in good condition with no rot. Water level was even with outlet invert. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: ❑ leaching fields number, dimensions: 3 34' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 3 leach trenches 34'x W'. Soil and stone was probed in various areas and found dry with no signs of past saturation. 12. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts !F�s' p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 47 Old Strawberry Hill Road Property Address Edward&Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. City1rown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Tmi,,)-flr26'0" B= 16�4, Oi1'l/L11ATHw/ ��v �� . ft 47 (` lei e:rtG T►t&4tf Bros $ G.ic MnwJ A-3A'O' S_SgIQrD naa,t � ps3310° �=406r pF,CIG a (�A:Z3'0" :41"0" r v r i tSmsp.doc•rev.726f21118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Edward &Gildete Thomas Owner Owner's Name information is required for every Hyannis Ma 02601 3/25/2021 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 � s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �., . 47 Old Strawberry Hill Road - Property Address Peter O'Sullivan r Owner Owner's Name i information is required for every Hyannis MA 02601 October 26,2014 ,, page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered lipany way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: ice/ key to move your cursor-do not David D. Flaherty Jr., IRS, REHS use the return Name of Inspector key. Flaherty Environmental Services r� Company Name P.O. Box 81 Company Address Yarmouth Port MA 02675 ' Cityrrown State Zip Code 508-362-1657 SI#4713 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority October 27, 2014 Insp ctor'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. II t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owner's Name information is required for every Hyannis MA 02601 October 26, 2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 , r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owners Name information is required for every Hyannis MA 02601 October 26, 2014 page. City/rown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owner's Name information is Y required for every Hyannis MA 02601 October 26, 2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into,facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owner's Name information is Hyannis -MA 02601 October 26 2014 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)..Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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•3/13 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 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owner's Name information is required for every Hyannis MA 02601 October 26, 2014 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual). 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner owner's Name information is required for every Hyannis MA 02601 October 26, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d '13: 304 gpd; '12: 9 ( Y 9 (gP ))= 335 gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2014Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ',❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owner's Name information is required for every Hyannis MA 02601 October 26, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? f Reason for pumping: Type of System: ® Septic tank, distribution box, soil.absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form c Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owner's Name j information is required for every Hyannis MA 02601 October 26, 2014 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: 12/10/2001 per BBOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >50 feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints tight, venting through dwelling adequate, no evidence of leakage Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon 3" Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments > 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owner's Name information is required for every Hyannis MA 02601 October 26, 2014 page. Cityrrown State. Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" 1 r, Scum thickness 8" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? dip stick, tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): maintenance pumping should be performed every two to three years, inlet&outlet tees good, tank seems structurally sound, liquid level appropriate, no evidence of leakage 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owner's Name information is required for every Hyannis MA 02601 October 26, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons, Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owner's Name ; information is required for every Hyannis MA 02601 October 26, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): dbox seems level, no evidence of leakage 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: • J t5ins•3/13 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 ,. 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owners Name information is required for every Hyannis MA 02601 October 26, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (3)2'x 20'x 2' t ❑ 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.): soils sandy with gravel and cobbles, no signs of breakout or hydraulic failure, stone is clean, vegetation typical (lawn) 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 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owners Name information is required for every Hyannis MA 02601 October 26 2014 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owner's Name information is required for every Hyannis MA 02601 October 26, 2014 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A-1 C Z' _ .S9 1i 4 1 rc i413 - z 63 ' ZR`�u t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM , 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owner's Name information is Hyannis MA 02601 October 26, 2014 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >10 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: hand augered to 10', no groundwater encountered Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 47 Old Strawberry Hill Road Property Address Peter O'Sullivan Owner Owner's Name information is required for every Hyannis MA 02601 October 26, 2014 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWiv OF BARNSTABLE .L I,iaCATION 7 old S w�fM 11.11/ M SEWAGE # f V?-LAGE H14 ., ASSESSOR'S MAP & LOT 1 f �` (67K) 77S INSTALLER'S NAME�Bt PHONE NO. �a.^<��/' SEPTIC TANK CAPACITY .2 .� ,. ` LEACHING FACILITY: (type)(R, 'x.2`x 3 y_ j (size)' '. , NO: OF BEDROOMS -3 BUILDER OR OWNER t PERMITDATE: lfi-l2 -U/ COMPLIANCE DATE: l a�/�`U / Separation Distance Between the: 7 Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by o_ '� 9J Dim � A� w �� o a Z Fh Fli � r a z 'l ;r�779t � hv�n a uvr.t/�bt THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair (1e) Upgrade ( ) Abandon ( ) - Z Complete System ❑Individual Components lee Location e��4��i ` Owner's Name Z y 9 // 1M k 5� � �- /G� 0lt Map/Parcel# Address p o 101P^C-o /�109 Lot# Telephone# del®.40-'s; a, de a c 12-,Q e�1 Installer's Name _ Designer's Name !ti yi4/df9 Address Address Telephone# Telephone# Type of Building: X d S / 0 Lot Size /.f3 Sq.feet Dwelling—No.of Bedrooms 3 Garbage Grinder /?Ov Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) gpd Calculated design flow gpd Design flow provided Y�ro?gpd Plan: Date 0 fl /O —Q/ Number of sheets B Revision Date Title if 0j�Q/Ee6 O i 1�i2 s.f`� S Y�iJ�1 0 Description of Soil(s) u` e— --- 4— Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation /1"? DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date �.�1/;Zk, FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 -•NO��ff�.�i` THE COMMONWEALTH OF MASSACHUSETTS FEE 45 91,0" BOARD'O F HEALTH l/ OF Rve �- ST�•�C c" - t APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair (IO Upgrade ( ) Abandon ( ) - ,F Complete System ❑Individual Components e�1L c O;L Location Owner's Name ' Irn Tviap/Parcel# —� Address .a/� / Off r Lot# Telephone# E✓� Q / �y r G ©*e- 5 >t Installer's Name Designer's Name Address Address Telephone# w Telephone# Type of:Building: Lot Size 15'3✓`­_1_ Sq.feet Dwelling"-;No'of Bedrooms Garbage Grinder "-,-.Other-/Type of Building rr i No.of persons Showers ( ), Cafeteria ( ) Ot ' Sj i ther fixtures - C V Design Flow)-(min.required) .3.r✓gpd Calculated design flow gpd Design flow provided gpd Plan:,Date,- - !,O- - /7/"' Number of sheets / Revision Date Title ~ 'S L-,�4/ 4 rV STr/y AV t' / r(c,tj� L�tv� Description,of Soil(s) 5, C .G Soil Evaluator Form No Name of Soil Evaluator G. e-e-! Date of Evaluation / ,-,7 v - DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. g ' 1.L//�Uj Si ned �^ Date FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96- THE COMMONWEALTH OF MASSACHUSETTS FEE _ 0/y57A/�'L/BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: . � l at c..1' / . has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5 and the approved design plans/as-built plans relating to applicag .J dated*f— 41 Approved Design Flow (gpd) Installer Designer: Inspector l/ 'IL Date 1A.2101 The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DER /DPP-ROVE-D-FO•RM,;S/96 THE COMMONWEALTH OF MASSACHUSETTS FEE f�C�t BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct epair ( ) Upgra ell b_ don ��`) an individual sewage disposal system at _ T3' / ,7&',A'easaescribed in the application for Disposal System Construction Permit No. datedA0 ..Az-Z!!:�f Provided: ConstrIm/900 ction shall be completed within three years of the date of this t mit.A local condition must be met. Date 1 I Board of Health - ' 'I FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON f r TOWN OF BARNSTABLE LOCATION 17 old S4:w r'Y �� !d� SEWAGE # -20d � VILLAGE� ASSESSOR'S MAP &LOT F INSTALLER'S NAME$z PHONE NO. �✓' 49 /' 6 . 77S,TSci 7 SEPTICV TANK CAPACITY. S7J® (z LEACHING FACILITY: (type) C ) .2'9t.2�x 31/_ j _(size,), NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: Al-/2-O/ CONiPLIANCE DATE: JA0A 1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of We and Leaching Facility (If any wetlands exist within 300 feet;of leaching facility) Feet Furnished by 13- )314" ®1s?a1a�b17°�urJ f3�v - r�� Av 4A'511 8= 25 f 7r' EAC ii o� '�11Fyv61i �W j'S 8 Z . A 3di 10d' S6100' Y2 earl. G►N mold A 3-310" 451 b" e- Q�'Gle � 1 rt_ n Oct? 05 01 07: 43a p. 11 �/V4A• ✓a.� ..1V� ' ASSESSORS MAP 249, PARCtL 113 I 5/i101 NO'1'YCk This For Is To Be Used For the Repair;Of Failed i Septic Systems Only. i I i I PF:RCOI<,TION TLSI AND SOIL '� LU4TTON FXFMlPT1oIV j FORM 1 f DAVID J. i I Cl�1SPTN hereby certify that the engineered plant stoned by me �' ! 10/5/01 i dated co,icierning the property located at _. 47 OLD STRAWBERRY HILL ROAD l meets aft of the following criteria: i • This failed system is connected to a residential dwel►ing only. There rue no tit comercIj1 or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation 'rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fac:or may conduct preliminary tests st the sitc without a health agent present, • "Mere is no increase in now anii/nr change in use. proposed I 4 Thcre are no variances requested or needed. I I • • The bottorn of rlrc proposed leaching facility will riot be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: -- - 5$ --- A) Top of Ground Surface Elevation (using GIS information) _ 27 !6) C9.3 _ 363 1 ,W. Elevation +adjustment for high G.W. _ 1)1FFERE C E BE- ' N A and 8 21•'7 S MWED DATE: V'7 of VNOTICE Based upon •rc above Information, a repair prariir will be issued lot 3 bedrooms Maximum, Noadditional bedrooms are authorized in the future without engineered septic system plans I l � � I q llcolth IuWer percexmp i i � I i � i I � I I I is 41 7i K 1 //(3 5/25/01 1 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM h , hereby certify that the engineered plan signed by me dated , concerning the property located at 7 �/J, �i�i✓y ��� CPi4 meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. q4ca • The soil is classified as-CLASS I and the o r is less than or equal to 5 minutes per inch. The applicant may use historical d o conclude this fact or may -" conduct preliminary tests at the site withou a th agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable]' Please complete the following: A) Top of Ground Surface Elevation (using GIS information) B) G.W. Elevation 21 + adjustment for high G.W. 7. r r DIFFERENCE BETWEEN A and B ?,y V SIGNED : DATE: NOTICE Based upon the above information, a repair permit will be.issued for bedrooms maximum. No additional bedrooms are authorized in the future'without engineered o septic system plans. q:health folder:percexmp sai z s x LO CAT.IQN SEWAGE PER`IM1T NO _ J �. /p (did 9r/lrAw$�aeq ' 7SJ_ VILLAGE LNSTA LLER'S : IdAIE, ADDRESS a B U It DE R. OR OWNER F 1 VoQ f y yr r ILIAIZ DATE PERMIT ISSU D DATE CO'IMPLIANCE ISSUED' � /_ 7f- — L fei ,g3 i f i !. 1 Nil '1 I1 f e 1 Ix c rh �6 - f t V. Ir t 6 { s f . ��j1�fJeaa, 64 f1 6 6 AZbA46 &C-1 QVeZ1 s t�:tz. "v�f C'Low ltco .c. 3 ?3 S Z�:- G T ALJ tL 3.t'c [ts,O ��(, *. 4 9 do o ' p 15 PUSAt- P t T Va;E= I, v a o G A t, J Si DES /ALL A2.EA = I s c z J, Is`O S.F. r`a PPGP -<,K L9 sC. S. F. 1 p . So To-rA�- '[>Est 6 N - 4 2;., �•. P. D. J P:�L.A"�'40" . RATC-_ t t w Z Mj" oQ C..�r5. N IZp . 30 •, ., � 1 el t }. $yxTc a k 4 I }� -Fe-iT i oP F4JDOVX 4'Pre 4 PE Gc�b •:a lint• q 7 D � �w p06r Intl/. ��- sua r ;DK$rrrz c+a� 4At_. 91. 7o 9t 4 �i6rPTIG kS.3 T�.u4c GAL. McDw�-t LEAPi C1l L. SNmr NJ1T4l . vrt 314 (�t sTu•a'E: W�Ktt&A i e-Mwrk f � b: i.10 d1.I 104,4 ►�o wF: Tt= SGAL� pt�T 3 / L � l CTI F%f T"A-r T"r-- P G i;t1 D F,; ; v t.; St,.tow t.l ►-�E2 o r-t COAA?�.-{S w t r H Tµe.. 'St�i.t►.a.� A► l>. 1,EV-8,AcI< 9r--Qote�AnEuT&, of Tw& i_ G.T to . Fr-. L . C . 3Z 84 � A 2 �sTE Q� Lal�n SvevE{oe�... T%419, PLAQ 14 UOT ' $45ED 04 AU lt_vT�'. AA A- 5ue�c�. Tug OFF5ET2 5 00Lt> hL To -P TEZm:Qt1 LOT L.IUE,. APPL►C A I+l T C P, G'� `"r :.::c ►..'� 1`_t_ �a. 1 ONS,NOT TO SCALE NOT TO SCALE C,-,HIN'G*,, TRENCH '' DETAIL.SOIL TEST PIT DATA- SE P TI C TAN K ' D E TAI L' i ,,.l.,'50Q GALWN DISTRIBUTIOWBOX' OETAIL DES�RIPTION bATE NOT TO SCALE NO. OF OUTIETS TEST PIT NOTES: 1. SEPIC TANK SHALL BE STEEL INLET AND OUTLET TEES TO BE CASTIRO , FINISHED GRADE 6* MAX VtR GRD. P-L., REINFORCED CONCREE. SCHEO. 40 PVC OR tA$T-IN--!PLACE ONCRETE ItES TO BE: CENTERED UNDER MANHOLE COVER. 2' WALJ.S FINISHED GRADE EST. HIGH GW. 2. SEPTIC TANX TO WITHSTAND 0�40 LOADiNG" �D�A EAS NO TI E& LOAM SEED DiStURBE UNLESS UNDER PAVEMENT, COVER ITRAVELED WAYS, A44EqEIN H .OLOADING 1, DIST. BOX TO WITHSTAND H­10 L SHALL APPLY.,6" Pvo 6Aw Fp A P ENDS' '3. ALL Plpt-:LCONNECTIONS ANt�' CONCCPETI: rw,DRI�ss 'OR: UNLESS U14DER PAVEM 7 HIGH GROUNDWATER COMPUTAT16 T 4" PVC,��,CONSTRUCION SHAli BE' WATERTIGHT, 2-24" DiA CONCRETE MANHOLES TRAVELED WAYS VM5RCIN _2261OADiNG APPL , mro,",Dm 4� FILL ALL UNUSED KNOCKOUTS -WTH 6' OF FINIS14 GRADE TION OF,GROUNDWA MORTAR. GENERAL NOTES, kNlAND PLAN --bR DESIr. TER± pu 8 2. PROVIDE,INLET TEEE OR BAFFLE -T,/FT OR 6" 5 TEE TO BE U IT, 24" ELVEVA � -T�s L I I I MAXIMUM WATER'LEVEL ADJUSTMENT' NDER E,OF POE'EXCEMS'0,08 f -1H IS T PUMPED SYTEM, `TRUCTliON 01`�­THE",SEWAGE C-1 IN ELEvA*noN or HIGH wATER - 4'CONTOUR M MEDlYM ,SAND 1992 GROUNDWATEP ST� ':b SPOSAL,:FA0UTY'ONLYI,.,2.5Y /4 AP IRST'TWO FEET OF PIPE OUT,OF D)4 3. F E MIN,_3 TO OX TO BE LAID LEVEL,'EWE ALL;CON U ON METHODS AND -S p E E- A OFILE MAWRJALS,SHALL,:CONiF`OPM'To ON L PR 48" L A 4" ,,k MORT Rr CRO CTION 1 1/2. of(us, 4� ALL PIPE CONNECTIONS AND CONCRtlE, D�t.Pi TITLE n'S 'AND LOCAL,BOARD S C 2* 'STONE 'SSE`�1,2* 36' MAX, - 12" MINI. OVEk-CONSTRUC17ON SHALL BE WATERTIGHT. '�,REGULAMONS.-I ,.Z. ALL,I5. FILL ALL UNUSED KNockoms WTH UORT `R. 4* MIN, LOAM SEED E�S LOC'A PRECAST SEPTIC TANK WAY:SHALL" BE. SCHEDULE"4o,,bR QUAL.. IINLET TEE 30 4 1.4 L ATED 14_v TAIN. m, T, 'NOR,PR600SED �tXACHING'fACWTY'M SAND MEDIU I IOUID DEPTH- m 1/8 A JLJ i T.2.SY,,6/4 PRCCAST IJIST. 4' IWASHED 5TONE,�'.: 1 sox I5� IN VI,INDICATES Or;�E)(tA 3/4" tO lm HED STONE (k/2-!� bbbiLr, T6PS& S4USSOIL,AN OT.,M 1,32" __7_ OBSERVED.47.1 —WAS 6 IMP L 6 'RE 'A ATE- 7 1/2 p .1 , CLEAN GRNULAR'SOIL N 7^1Z PED_01:Ao C, AN BOTTOM ON LEVEL� STABLE BA!NO GROUNDWATER OBSER\�ED '(;ROUND WAT�R LAN NAEW DICATES V1 ROSS-EW'SECTION IER, ESTIMATED, 2r"z S N 'To Lol.1 Ao_1 TESY* IWT zc,� ROUP.­81 INC., GROU,,-lD WAIT,R,"THt 'o I 151 VE "SHALL PA S IIND 1�,�WAIVEQ:,8*�. TOWN 16-ATES DE7, GN",� CRM ' OF IRIA MCI`PERC _RATE. AMD J� A%N, Fww IX :51,'8 4,48 'A T 110 IIIBEOR.00 0.P.8./D 7�,7,7 JNDIICATE_S'� IIIT IG, ,F]EL 14632112� NSU b IA i TER(AL A A I 'TH -DR IAPPROXIMA I :7 I1) �:S TIC 09# 'OR PROPr_ 0 NG AND II40I M I IVIN vi I T ITA N K,,, O\4,Dr_D (INTAININO HE IIIF ILO I60 G A L TiA R , II581 IIy r I` 51 IF I --A' �MASS t IIIOF, DEStGN' JNC P D I4v IUND 0 IIHO4; L' F K 5ET: TOP� �DF CON '57' HE "DOES INOINE TOWN SE� M,APS II'D. iASSUMED ' ; ,R rUM ' V4 N IU T IIIB I 'T IRETE,C IIIIIIINO' j<T TO ,SCALE IT !tgAC FAC KING I T IIIIIIPIPE F S LENG11-4 IR T' IFOUNDATION 4;RS TO �WITHIN c AD FOR -'FOR, I7,�X 57,,'�FNISW cRAD tAO'A I612 F 6MUED t 3, IIT iou Ivrftll1_8* 3 7UF7n I�A 'E, I- 4 v I �,�,MATCH _E IIIIIIII­rANk 018 �`BOX NII5 OUTLETIj F VERVAT, 57,$ t OR IIIIts AGIC09DO IIn ITI T�r,v Im II�SEDROOMI IIA IS N FOR TM-,L U;NO EXISTII ISHE 1)"ELE, TI^NS- IR17 v C RO Bs60.9 TOP 01 J-OUNDATIQN A, &,T'OWNFR--, RELEN fl-SHAW C0`RRE _2 8)�Un IJJT IVE UILDING 5-7:. DECK N L-0 T 0 IIh assach ILE, REFERENCE. CERT JNVERT AT SEP 4 11C TANK ,(IN)' 57�0' C PL -ERENC'E '7 II245�ANART, AT .7' E 4 T .SEPTI,C TANK (OUT)-, AN qET IERT� A 5", D LC. 2$929 '13, 2 05 p QJECTjlt� DIST. BOX (,IN) �4iSSt ,dqS :MAP: :PR F 4 IN R 7 AT, DIST. BOX (OUT), SMACKS: 'FRONT 2.0'TRCT DIS 0KNO b151 EWAGE POSAL IJNVF -IING FACILITY: N sy _RTS AT LEAC4 a EXISTING GE IBEGINNING -3.0 REAR 10'\,�GRA 4 :'INVERTi AT -P RE, AI­017 EACHING irk�NCH 55.77 G �WNIWJV LOT SIZE: 43,5�0, 8Y.wp:'RLAY DISTRICT:t 'OVE II-4 IOGE' N --SENSIJIVC ZONE It ONE:IY ' FEM A 'FL ZON E TR C-*_,��Q �,LEACHIN H 7 M R �4 IN`,,v`EkT: AT END G -TRENC 55.60' H -LEVATION AT BOTTOM_ OLD I AV of$ In DATED 8/19/85 , �,,H :ROA IOF iLEACHING�JRE CH N 53.6' i # IIPANEL I LL E A Lv L N- NO SCAL'1 7.3± SEPERATION Cu S, N�HYAN :I CO�CRETE f3 WD,ESTIMATED ADJUSTED GROUNDWATER 36I3± K I MAXIMUM ' AD JUS,t�tN­T".II1ARRINGTO G�RomowATER BASED ON R ' GLEN iH IN PE�MAPS INT T011��N 27± I L BOARD�,�'OF :,H ALTH,,,,A, A II/V �PREPA 0 kcb IIAN' 'ICA ETE-1 'W-PE TER��'SIJLLI SET,K I70 F' IELEV I7 YARM TH,T�I57'NGvD LOT ll 0 A I0 2617,.3 IL YLITILITY LEA 57�VARIANCES' REQUESTEU OT 6LE L 13 C U IUTILITY IIDE-14 40M IIWN IIIc fk, 'NONE: , ":, .I I I I , :� , I 1 8 kt IN II '76 w IR E V I T r CAT ,IIE T� IIQALE�-' I'T' IIIIIIIII