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HomeMy WebLinkAbout0052 OLD TOWN ROAD - Health 52 Old Town Road Hyannis A .192-043 r �I i i { �t� 'SOWN OF BARNSTABLE >J/ 7,r>C LOCATION Olt,( SEWAGE.# VILLAGE ASSESSOR'S MAP&PARCEL MIS NAME&PHONE NO. 14o*.0 .&b#4soA AAc 5di4cc 775177-4.' SEPTIC TA K CAPACITY LEACHING FACILITY:(type) C/,4 .�A/Am* t (size) NO.OF BEDROOMS OWNER PERMIT DATE: €E}fvtt1tf7t E DATE: '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 Wetland and L•.,aching Facility(if any wetlands exist within 300 feet of leaching:facility)., '' feet FURNISHED BY O. w . 1 T III � e ®. r TOWN OF BARNSTABLE IF 0�2) SEWAGE # VILLAGE / `�� ASSESSOR'S MAP &LOT A 4?' ®4�3 NSRE eyes NAME&PHONE NO. Al C G SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size)NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: OMP6hOiGE DATE: 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 Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by .. r Cp, ys� �., (..:� c 4.� ^. , � M �� � ' O A Y • �� r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is annis-Pert �� Ma 02647 3/10/11 required for every S page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B & B Excavation, Inc. „y Company Name 14 Teaberry Lane Company Address Sandwich MA 02563 Cltyrrown State Zip Code 508477-0653 S14595 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 3/10/11 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. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Dispos System•Page 1 of 17 c Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is required for every y W. Hyannis Port Ma 02647 3/10/11 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I Commonwealth of Massachusetts W Title 5. Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,.•''F 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is required for every y W. Hyannis Port Ma 02647 3/10/11 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is required for every y W. Hyannis Port Ma 02647 3/10/11 page. CityrFown 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 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 fL 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 %day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts i - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 52 Old Town Road Property Address Pamela li -L a e a L a berte ebeau Owner Owner's Name information is required for every y W. Hyannis Port Ma 02647 3/10/11 page. Citylrown 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. ❑ Z 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is required for every y W. Hyannis Port Ma 02647 3/10/11 page. CitylTown 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? I ® ❑ 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): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 l5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is required for every W. Hyannis Port Ma 02647 3/10/11 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? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? Yes ❑ No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: August 2010 Date Commercial/Industrial flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203)- Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No. Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 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 M 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is required for every y W. Hyannis Port Ma 02647 3/10/11 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? 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 El Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09108 ` 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 M 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is required for every y W. Hyannis Port Ma 02647 3/10/11 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: 8/24/2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage 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: 5.8x5.8x10.6 Sludge depth: lit t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is required for every W. Hyannis Port Ma 02647 3/10/11 page. Citylrown 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 39" Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good shape tees present no sign of back up 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•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts AmmW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 52 Old Town Road Property Address Pamela li a e a L a berte-Lebeau Owner Owner's Name information is W. Hyannis Port Ma 02647 3/10/11 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 't5ins•09/08 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 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is required for every y W. Hyannis Port Ma 02647 3/10/11 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.): At time of inspection d-box appeared to be in good shape no sign of carry over or Ieakage.Water level was equal with outlet invert. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 r Commonwealth of Massachusetts - Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is required for every y W. Hyannis Port Ma 02647 3/10/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: leaching chambers number: 4 Infiltraters 11 x25 ❑ 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.): At time of inspection leaching appeared to be in good shape no sign of staing or hydraulic failure.Inspected leaching threw inspection port and leaching was dry. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 52 Old Town Road M Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is required for every y W. Hyannis Port Ma 02647 3/10/11 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•09108 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 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is required for every W. Hyannis Port Ma 02647 3/10/11 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 -ReA-P- OF t,ous1F A C� At `g ' A3 ' 1113u 1T "," 4= 3S' 7" l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name information is required for every y W. Hyannis Port Ma 02647 3/10/11 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: >13.7 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: April 14,2008 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: Observed plan on file for#38 Old Town Rd. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Old Town Road Property Address Pamela Laliberte-Lebeau Owner Owner's Name requir required for W. Hyannis Port Ma 02647 3/10/11 required for every y 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•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 Z_Szs'-( e i , COMMONWEALTH OF MASSACHUSETTS z w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTECTION ia�M SV e� 350 MAIN STREET WEST YARMOUTH,MA O V� 508-775-2800 F tiF° e I3���Z TITLE 5 r q) OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS yOicpTTge�F SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION .7 MAP 267 PAR 063 Property Address: 52 OLD TOWN ROAD HYANNISPORT,MA 02647 Owner's Name: GRASSY,KATHY Owner's Address: 34 WINDSOR PARK ROAD LOWELL,MA 01852 Date of Inspection DECEMBER 4,2002 Name of Inspector:(please print) JAMES D. SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT 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 Needs Further Evaluation by the Local Approving Authority ails 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****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. I Title 5 Inspection Form 6/15/2000 1 I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 52 OLD TOWN ROAD HYANNISPORT,MA 02647 Owner: GRASSY,KATHY Date of Inspection: DECEMBER 4,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: .( 1 have not found any infonnation 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: N/A 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 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 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 obstruction is removed distribution box is leveled or replaced ND explain: 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: Title 5 Inspection Form 6/15/2000 2 i Page 3 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 52 OLD TOWN ROAD HYANNISPORT,MA 02647 Owner: GRASSY,KATHY Date of Inspection: DECEMBER 4,2002 C. Further Evaluation is Required by the Board of Health: N/A 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 salt marsh 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 52 OLD TOWN ROAD HYANNISPORT,MA 02647 Owner: GRASSY,KATHY Date of Inspection: DECEMBER 4,2002 D. System Failure Criteria applicable to all systems: N/A 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 leaching 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this fonn.) NO (Yes/No)The system fails. I have detennined 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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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—1WPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 52 OLD TOWN ROAD HYANNISPORT,MA 02647 Owner: GRASSY,KATHY Date of Inspection: DECEMBER 4,2002 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 J 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? J 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) J 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)has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. J 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(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 52 OLD TOWN ROAD HYANNISPORT,MA 02647 Owner: GRASSY,KATHY Date of Inspection: DECEMBER 4,2002 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): N/A [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use(yes or no): YES Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) NO Last date of occupancy: UNKNOWN COMMERCIALANDUS TRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pu nped: gallons—How was quantity pumped detennined? 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) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 2000 PERMIT 2000-501 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 OLD TOWN ROAD HYANNISPORT,MA 02647 Owner: GRASSY,KATHY Date of Inspection: DECEMBER 4,2002 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 6" Materials of construction: Cast iron P/40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 10" Material of construction: ✓ concrete metal fiberglass polyethylene other(explain) If tank is metal list age: Is age continued by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,500 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: 12" Distance from top of scum to top of outlet tee or baffle: 0" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions detennined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL.INLET TEE,OUTLET TEE.TANK AND COVERS 10"BELOW GRADE. NO SIGN OF OVERLOADING SEEN IN TANK. GREASE TRAP(located on site plan) N/A Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 p 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 OLD TOWN ROAD HYANNISPORT,MA 02647 Owner: GRASSY,KATHY Date of Inspection: DECEMBER 4,2002 TIGHT or HOLDING TANK: N/A (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/day Alarm present(yes or no) Alann level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alann and float switches,etc.): 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 1S 16"X16",T BELOW GRADE.ONE LINE IN,ONE LINE OUT.BOX IS CLEAN AND SOLID.NO SIGN OF OVERLOADING OR SOLID CARRY OVER SEEN. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alanns in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 OLD TOWN ROAD HYANNISPORT,MA 02647 Owner: GRASSY,KATHY Date of Inspection: DECEMBER 4,2002 SOIL ABSORPTION SYSTEM(SAS): ./ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 4 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.) LEACHING IS FOUR INFILTRATORS—I J'X25'. LEACHING IS 3'BELOW GRADE. DID TEST HOLE AND PROBED ABOVE AND BESIDE LEACHING.NO SIGN OF OVERLOADING SEEN. CESSPOOLS: N/A (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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 f Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 OLD TOWN ROAD HYANNISPORT,MA 02647 Owner: GRASSY,KATHY Date of Inspection: DECEMBER.4,2002 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 building. RL6 /R 18' 0 0 30 Title 5 Inspection Form 6/15/2000 10 i Page 11 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 OLD TOWN ROAD HYANNISPORT,MA 02647 Owner: GRASSY,KATHY Date of Inspection: DECEMBER 4,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 10 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: J Observation 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 DUG TEST HOLE,NO WATER AT 10'.BOTTOM OF LEACHING 4'6"BELOW GRADE. 5'6"ABOVE TEST HOLE. 7• N • M t $ o/To,•a l o ti Iv o 4v,4 2 Title 5 Inspection Form 6/15/2000 11 i No. Fee Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppricatfon for Migo r *pgtem Construction permit Application for a Permit to Construct( )Repair( )Upgrade-bandon( ) Complete System ❑Individual Components Location Address or Lot No. O/D'Touc Owner's Name, ddress and Tel.No. Assessor's Map/Parcel �J pca t vv o ��`� Installer's Name,Address,and Tel. 0 No. ( � Designer's Name,Address and Tel.No. r�-G6, sr� Type of Building: Dwelling No.of Bedrooms IS Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �n�) cS��aG—�r9 Type of S.A.S. 14r .c i Li Description of Soil: C=Aluz o Nature of Repairs or Alterations(Answer when applicable) Cq i7` a ti Oh % 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 t lace the system in operation until a Certifi- cate of Compliance has be y s f Signed Date Application Approved by Date f —0 Application Disapproved for the fo owing reasons Permit No. Date Issued No. ,,�/7 Fee 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s ` PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Migo!aY *p!tem Congtruction Permit r S Application for a Permit to Construct( )Repair( )Upgad�andon( ) �Com lete p System ❑Individual Components Location Address or Lot No. 5 d- O/®TO Owner's Name, ddress and Tel.No. . E�j��1 r !moo ��--�.. Assessor's Map/Parcel "?_0�3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. — Get S/vLA c ST, � Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow `­5 3 U gallons_per"day. Calculated daily flow er gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank � sP�/`� _1W1 Type of S.A.S. r .>-Description of Soil �t°'�G � r( /,I l'S e, 5 Alature of Repairs or Alterations(Answer when applicable) / �( S-�lJ� C �T t�L (S 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 Certifi- cate of Compliance has beon-issued b—y l-s Biow. f h. Signed i Date Application Approved by Date U . 6 Application Disapproved for the o lowing reasons Permit No. . a nr e a _"r0;l Date Issued r' --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(Ik j� Abandoned( )by C 1 L at © tc K/ c C has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construc 'on Permit o. dated / Installer 1 Designer s The issuance of this ermit shall n.tW_,onstrued as a uarantee that e_; ste wtll functio as designed Date p 0 g Inspector y /�'�;` P V L/d111i 19 ))"i _ ----------------------------- --fir— _----- 1 y�l No. -c LnQ 5��0 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigpooaf 6potem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade k_,�,Abandon( ) System located at K ., 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 permit. Date: -��!�?3�J Approved by 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated pww—6-)�? , concerning the property located at ,j �- O f %</L� �� /7`�P��/ meets all of the following criteria: 141 This failed system is connected to a residential dwelling only. There are no commercial 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. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system 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 five feet above the maximum / adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when / applicable] /•/ If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted ,groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation J`LI? +the MAX. High G.W.Adjustment/ ,e _ t DIFFERENCE BETWEEN A and B 0 SIGNED : DATE: [Please Sketch p osed plan of system o ac 1. 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 septic system plans. q:health folder:cert D .f _ TOWN OF BARNSTABLE LOCATION SEWAGE # �� I VILLAGE �,.. ASSESSOR'S MAP & LOT '�� INSTALLER'S NAME&PHONE NO. ..'. SEPTIC TANK CAPACITY - . LEACHING FACILITY: (type) lT/�T.�if%o,P ) (size NO. OF BEDROOMS.BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water;Supply Well and Leachin Facili 8 ty (If.any wells exist r_ `on site or within 200 feet of leaching facility) ' Edge of Wetland and Leaching Facili y Feet g ty(If an wetlands exist within 300 feet�of leaching facility) y, Furnished by Feet r i i r i T( � {/ � t 1 Q 1i .� , O _ TOWN�C F BARNSTABLE LOCATION O l D 9 o WIl ILI SEWAGE # Il.LAGE L&/.4&dZZ C dQQ A I ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /d'd /,;9 c, iLl e S P.�✓�/ G SEPTIC TANK CAPACITY 6 Sd ie LEACHING FACILITY: (type) f�i�sf%O/P�' (size) NO.OF BEDROOMS BUELDER OR OWNER '- PERMTTDATE: '' COMPLIANCE DATE: Separation Distance Between Maximun4dj sted Groundwater Table to Bott the om of Leaching Facility Feet Privaie"Wat i,Supply Well and Leaching Facili%4.(1f "' ,.wells exist,,.4,� on site'or within 200 feet of leaching facility) t Edge of Wetland an'&I-eaching Facility(If any wetlands exist " within 300 feet-.of leaching facility) �� �'" Feet I 'furnished by • 4 r If_ _ J d sZ f y Y .I } _ t _ •` t COMMONWEALTH OF MASSACHUSETTS kipEXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION GG ti Property Address:_J�` Owner's Name. Owner's Address:__$I;;L olefG�..,. Date of Inspection: to dJ � —T—T Name of inspector:(please print) Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5081 775-8736 ' CERTIFICATION STATEMENT 1 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 f tncti and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to ection 15340 of Title 5(310 CbIR 15.000). The system: _ _Y.. /. Passes .. Conditionally Passes -Needs F tuation by the Local Approving Authority F Inspector's Signature: gate: (o f 01AVF The system inspector shalt submit a co of this inspection report to the Approving Authority Board of Heatth or'�' »Y P PY �p� fm PP g h' 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 shalt submit the.repott 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. Notes and Comments ""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., :,..Fro Title 5 Inspection Form 6/1512000 page I r Page 2 of 11 F ' s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 5i;k n Owner• 4 Date of Inspectlon: f o Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst Passes: 1 have not found an information which indi cates rcates that any of the failure l e trite 15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below.cubed in 3!0 CMR 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".picase explain. , ]be septic tank is metal and over 20 years old'or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exliltration 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 obstructed pipes)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 - M obstruction is removed distribution box is leveled or replaced ND explain: , The system required pumping more than 4 times a year due to broken or obsw cted pipe(s).The system will pass inspection if(with approval of the Board of health): broken pipe(s)are replaced obstruction is U=vcd ND cxplain: _ 19 `Page 3 of i l OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:5a 0 ta 0143 \ ,emu Owner. Date of Inspection: .. /f 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 envii onment: _ 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 Z. 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 environments f ' _ The system has'a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a' - surtace 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 colifoun bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: ... fir., 3 Page 4 of 1 I , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:5a Owner: Q 1- �- - Date of Inspection: l o� 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 V 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 V,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. �f Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. . t Any portion of a cesspool or privy is within a Zone I 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 Kato " supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria ,� 1 are triggered.A copy of the analysis must be.attached to this form.] . . . i I /0 0 (Yes/No)The system fails.l have determined that one or more of the above failure criteria exist as described in 316 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 alarge syste the system must serve a facility with a design flow of 10,000 gpd to I5,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no ____ ___ the system is within 400 feet of a surface drinking water supply _ , the system is within 200 feet of a tfibutaiy to a surface drinking water supply A the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone I of a public water supply well If you have answered"yes"to any question in Scctim E the system is considered a signjfjcarit threat,or answered "yes"in Section D above the large system has fai'kd.The u%mer 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 3I0 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page.5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 1 CHECKLIST Property Address:,5a ot6 iolv !l"Un 0 0 Owner:� h Date of Inspection: to oc S' 4 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: YCS O _ 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? „ r ' _ _ 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? TWere 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? ` J_ 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 .} . yofthbaffles 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 i maintenance of subsurface sewage disposal systems? ,. The size and location of the Soil Absorption System(SAS)on the site has been determined based on:, Yes no - Existing information.For example,a plan at the Board of Health. V — 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(3)(b)j • ,t i 5 Page 6 of i l '. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address•JaO(aT( wy_l Owner.• �Q t Date or inspection: FLOW CONDITIONS RESIDENTIAL . _ Number of bedrooms(design):,3_ Number of bedrooms(actual): yZ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 3 Does residence have a garbage grinder(yes or no): ^AD Is laundry on a separate.sewage system(yes or no):A° [if yes separate inspection required) Laundry ysYstem inspected(yes or no : A- Seasonal use:(yes or no)vyO Water meter readings,if available(last 2 years usage(gpd)): -1/M -3/0 t 32 SOO Sump pump(yes or no): !LL) 3�p(o- No? Z�,00D Last date of occupancy: COMM ERCIAIANDUSTRIA L Type of establishment: /v Design flow(based on 310 CMR 15.203): gpd - ' Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ +' Industrial waste holding tank present(yes or no):_ < Non-sanitary waste discharged to the Title 5 system(yes or no):, Water meter readings,if available: Last date of occupancy/use: ' OTHER(describe): r GENERAL INFORMATION Pumping Records Source of information: mac) — A4_r f lC C e� Was system pumped as part of die inspection(yes or no): Lvv If yes,volume pumped:__gallons--How was quantity pumped determined? Reason for pumping: -- TYPOF SYSTEM V Septic tank,distribution box,soil absorption system rn y 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 obta o med from system owner) Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if Mown)and source of information: Were sewage odors detected when arriving at the site(yes or no): ND 6 ID z c Co 3 �.. 5" ,�' n d" rt ^ e ^t o 3 ow Ia -ICA n a 21 F v a to kp v G n - C nCy U' o _^ c T► �, .: L - n y a v = n ^ C :z ev A cr G L A ._ _ � CA �. T O U Page 8 of I! OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSL;SSNILN-1•S SUBSUIU-ACE SEWAGE DISPOSAL SYSZ'EPi INSI'[1C•1•101q I-O)t111 PART C SYSTLPI INFORMATION(cuniinucd) rroperty Address: po 1 Owner: Date of los cc(lon: to p TIG11T or 110LI)MG TANK:L/t must-be wuP scd a '{ 1 t tune of inspection i ')( uca(_e un site plan) Dep1h below grade Material of construction:--concrete_lnetal_fiberglass_pvlyetbylenr othes(explain): Uimcnsions: Capacity:_ allvns Design flow; gaHunslJay , Alann present(ycs or no): Alarm level; Alann in wurkiu urdcr Date of last pumping; 6 V'cs ur nu). , Cununcnts(condition of alarm and flual s�silchcs,ctc.)- 4 it DISTI(JOUTION BO\:'t;f lrescntmu `s(be opcucd)(locate oil site pla�n) Depth of liquid level above ourlct inrcrt: Z> Cununcnls(nole if box is level and dislribuli- any cviJcnce to outlets cqual;' of Solids raPr}o�er,airy cviJcnce of IcakXinty or out of bux,ctc.): 1'UAII'CIIA111UCIl: `l�c`ale on site(Plan) Pumps in working order(yes or no): Alarms in Working order(yes or no):_ CVnmlen(s(nulc condition of pump chalubcr,cunditiun of pumps and appulicnauccs.c(c.): Page 9 of,l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM z I PART C ' ' I SYSTEM INFORMATION(continued) Property Address: Owner: ?Ctuy\ LAJU V94n-ic- Date of Inspection: c� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type _leaching pits,number:_ 3// 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 pondin„damp soil,condition of vegetation, etc_ : c> UT p n• v 3 vie '5A}S 4ti l Ldl �C�.¢`pN t��'11 ,rl,e} �-.z. '� pR:S � �J ►C �> � O Gt h�G� T�os�c�al CESSPOOLS:�Acesspool 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: a Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: �hlocate 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.): 9 Page 10 of 1 l OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: ` 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 building. AN►e 13 Czi 4 P, I Is 13' 10 Page 11 of 11' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ;CI Property Address: Q�Gt l OW-\ %5_4 Owner. 76"rN 1 r' Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting propertylobservation 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: N�Gr / kip)z i 3Z ^teJ ✓�s.J Regulatory Set-vices IAURNSTASLE, • Thomas F. Geiler, Director �ArF039. Public Health Division 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. Q:ISEPTIMisclaimer Private Septic Inspections.DOC r i f I z i Pr . Cam., -yam , NQ {{j , , i i 1 r _ ,,- - - .,.e• .-M1.t �'"'.,Y�.�.....�,-v^'y. --.".. 'b"'-..;.— +•r '" � I � - i`.�.-TaF ".'.^fir^*-^....�_ } _--•""`tip---•�,,, ,_.y„_��..B..aa! �I 9 � t I C _ r _ � a I , i R � c 1 ' I i OW r , V ' - _ ... t t i j I t t t 1 1 ooe I rwltl f ' 4 • i E - _ - - 1 { 6 f _ i 1 {. _I 1 E t 1 r r ' i .. t ; r Sat + • 1 V"At L 16" fpc lk �. I I ► , - 1__ i I �I k { I I � ' 3 , r t If 1 --` - __ ---,-- ---- - f r � 5 I ; I I ' } t • , t I k Tt FT- NX t � I f , I ; -.�-- -7 -h--1 - --r--�'--,-�--f i ? ' I I 9� u 1 400 - _ -- - - � zm -777771 mom O� a t t , t i . _ t U + - as } 1 � " I f _ _ ► ivo►Z,�G�� i } w� w- i a 7} r t { g$ ik n1 V' 'e•��Win+"v ;l . b i , i i , { i f O!b 4 , r _ � F l � 016►, I : : i I ► ; i t i `' t �8 yes r Jel I { )L.j o PT 1,4 ► � . .JEEP ---� U�l 41.E ��,�,G,FeeT ►� '•' _.. i r . i 4 • i Co t - a �_ V 1 . a .,p ;;-- _ Z s ��d x o U E x PORTION OF LOT 38 PER Z PLAN 17-49 & LOT 36 PER PLAN 85-105 LOCUS A.M. 267-062 CRAIG yl[,I,E t 70' PER DEED SHED �o o g ~ C DRIVEWAY N PROP S&D lag, HYANNISPORT .� •,�,���.�.� ADDITION LOCUS MAP PLAN REF 17-49, 85-105 &228-49-n EXIST/NC DECK DEED REF 19048-265 ,EXISTING,, J o tz, b b ...HousE... ZONING: "RB" ,,,,,,,,,, SETBACKS: 20'-10'-10" 20.7 zze' FLOOD ZONE: "C" a b PORTION OF LOT 38 & 39 PANEL NUMBER.- 250001 0008 D PER PLAN 17-49 DATED.- 07-02-92 b i i PROPOSED A M 267-065 CADDITION y PLOT PLAN OF LAND LOCATED AT.• AM. 267-063 2 OLD TO WN ROAD PORTION OF LOT 3e �, 5HYANNISPORT, MA. O PER PLAN 17-49 AREA=5571tS.F. b70' PER DEED �1,oaAAAA PREPARED FOR- AM. 267-064 e s�'y'°�'''�SS��.'�® PAMELA S LALIBE'RTE PORTION OF LOT 39 v®c=P�G\STERFO h61, PER PLAN 17-49 N A UG UST 23, 2007 e s S�EpHEN o DOY1.E REV- 0 oQ a REV- REV GRAPHIC SCALE YANKEE LAND SURVEYORS 20 0 10 20 40 80 & CONSULTANTS P.O. BOX 265 UNIT 1, 40 INDUSTRY ROAD MARSTONS MILLS, MA 02648 IN FEET ) TM 508-428-0055 FAX 508-420-5553 1 inch = 20 ft. SHEET 1 OF 1 JOB # 54267 JF L�