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HomeMy WebLinkAbout0133 OLD TOWN ROAD - Health 133 OLD TOWN ROAD Hyannis , A = 268 — 076 g2 &B-0- rL Commonwealth of Massachusetts "A Title 5 Official Inspection Form ` z� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments tin °M 133 Old Town Road Property Address M Joao Marcelo Owner Owner's Name information is Hyannis MA 02601 9-15-16 required for every try. page. City/Town State Zip Code Date of Inspe&n IlLn Inspection results must be submitted on this form. Inspection forms may not be ali6red in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information a�ufuunnq� on the computer, I r'+ `\�������jH OF/ygS�i,,��� use only the tab 1. Inspector: # I 1 d 70 �.�`ya�'• key to move your ;•' cursor-do not use the return James D.Sears �°:' DAMES 'yN key. Name of Inspector =�' SEARS :-�'+ yco Jim The Inspector Man =*' Company Name '.� TIIF P.O.Box 784 i�,���,F 5 I N SPEG Company Address nnmmt few West Yarmouth, MA 02673 City/Town State Zip Code 508-364-4398 S 1623 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 16.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority j.0_e4,4.A,_ 9-15-16 spector'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 should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 133 Old Town Road Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank- D Box and 12 chambers. 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.doc•rev.6/16 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 , 133 Old Town Road Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will ass with Board of p y p 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N 133 Old Town Road Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in MEMM is less than 6" below invert or available volume is less than '/2 day flow ,-&4(?#1A1-C t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 133 Old Town Road Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 f ri❑ y e o 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w v v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 133 Old Town Road Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 133 Old Town Road Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: the system is a 1500 Gal. Tank D Box and 12 chambers. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (9p ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 133 Old Town Road Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/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): l5ins.doc-rev.6/16 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 133 Old Town Road Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 page. CityTrown . State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2014 Permit # 2014 -218. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. Septic Tank(locate on site plan): Depth below grade: 8" 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 Gal. Precast H-20 Sludge depth: 1" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '- 133 Old Town Road AI 5y Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape- Plan Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at workng level. Tank and covers at 8" below grade. In and outlet tee's. No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feet i Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 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 133 Old Town Road Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 133 Old3own Road Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 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.): D Box is 16"x16"-18" below grade. Box is clean and solid w/2 outlet's. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 133 Old Town Road M SyO Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 12 ❑ 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 (12) Biodiffusr ARC 36 HC. Two rows of six units each row. Ck D Box and camera out chambers. Clean like new. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 133 Old Town Road Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 133 Old Town Road Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 . Assessing As-Built Cards Page 1 of 2 ,,TOWN OF BARNSTABLE LOCATION 3�l r� IOW 12ela/ SEWAGE# 16 l y—21Y VILLAGE ASSESSOR'S MAP&PA/RCEL,,1 — a 7G INSTALLER'S NAME&PHONE NO. rJS--10-9 ,r8 /O.�Coa:1��G ;�'/•=w SEPTIC TANK CAPACITY I d, LEACIBNNG FACILITY,(type) /_I . i ;�! (j;; (size) 3D X NO.OF BEDROOMS ? OWNER =r t PERMIT DATE: - ' COMPLIANCE DATE: 7•c7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility Of any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leachmg Facility Of any wetlands exist within 300 feet of leaching facility Feet FURNISHED BY 'r✓/:! r`e .. ' G t: n q /3p<k I3 t« oe , http://www.townofbamstable.us/Assessing/HMdisplay.asi)?mappar=268076&sea=1 9/15/201 f Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 133 Old Town Road Property Address Joao Marcelo Owner Owner's Name information ati is re wired for every Hyannis MA 02601 9-15-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N0 Estimated depth ta6i—gh ground water: 12-6 11 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: 6-17-13 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: T.H. on Desi n plan 6-17-13 no G.W. at 12'-6" Bottom of chamber's at 3' below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,••''r 133 Old Town Road Property Address Joao Marcelo Owner Owner's Name information is required for every Hyannis MA 02601 9-15-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater I ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t Y J Fee dV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: . Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4pliLatlon for Misposal 6pstem Construrtion pertnit Application for a Permit to Construct(Z-- Repair(upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./33 06.0 TDU-1;1 &,W / O ner's Name Address anq Tel.No. - Assessor's Map/Parcel z / Installer's Name,Address,and Tel.No.308-gea_q 13 Designer's Name,Address,and Tel.No. ✓a5eP4 J-e1jr4r� j/ H NS�SOCiATi-S Sob-9-33-nova 8/4 #11 vhS W111S O Co U/T " Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) r �2 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sig Date Application Approved by Date 7 1 LJ Application Disapproved by Date for the following reasons Permit No. J��' Date Issued 7 No Fee Entered in computer: THE COMM WMALTH OF MASSACHUSETTSYes PUBLIC HEALTH DIVISION ,TOWN :OF BARNSTABLE, MASSACHUSETTS 01pplication. foibisp"OsAY *pstrm Construction Permit Application for a Permit to Construct(Z-�- Repair(4f-'Gpgrade( ) Abandon( ) ❑Complete System ❑Individual Components c�/YI o� O ner's Name Address,an Tel.No.Location Address or Lot No./33 QL Tv / d - - Assessor's Map/Parcel 2 62 -07G 4el.s t/ GreFN� ,t Installer's Name,Address,and Tel.No. ' y20- �/93 8 Designer's Name,Address,and Tel.No., �'--= Jdv e 4 S Jl gff /�<-/�F-��-y;..�7T /2�G`G'�'�Stvr�S <19��/� 20 Co%v/T/2� S�.r�r�v✓rc�`1'I.�° �i1s"(o 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Z� S/-a/'/ f�//_�0i��1/o��/ �u ram/ Date last inspected: I Agreement: I _ The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. r ` s Si dt �� ., Date ` Application Approved by Date / Application Disapproved by Date / for the following reasons �i._. Permit No. c O L/ Date Issued 7 L _ I _ ------ -------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(y- Upgraded Abandoned( )b j by oJ e !4/i'&1 at /33 G'/C/ ✓�I `� f ft/la�/`I/S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction.Permit No?�''P/ edated 712�y Installer c� 4 //��� /� s Designer l'/ f/ dTGC GC/<9T-`S #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will function as designed. / // Date 4 /// /2 D j Inspector0, Y10,, d'Z i .. No. / _ -----Fee ----- --------- -- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION— BARNSTABLE,MASSACHUSETTS Disposal &pstem Construction Permit I Permission is hereby granted to Construct( ) Repair(4-) Upgrade Abandon( ) System located at i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. s Provided:Construction must be ompleted within three years of the date of thi permit. Date Approv�d by '! I y Town of Barnstable Regulatory Services Thomas F.Geder,Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: 7-9 Sewage Permit# Assessor's Map\Parcel Designer: Installer: f S WI /&Iy!may S Address: Address: 81 amew\ _A On — — Ja5gAh b&kP0 S was issued a permit to install a (date) (installer) septic system at based on a design drawn by, e,, (address) LIW J W=, dated b /7-13 ' (designer) 6,-�l certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank.. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&.Local Regulations. Plan revision or certified as-built by designer to follow. q o AW N VON PONE(Installer's Signature) 0 #1068 a Jesigner's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF 7 COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Heahh/SeptidDesigner Certification Foam 3-26-04.doc 36 ffc ff;Zo sf-a, �lq�1'e . .¢rt 3 ! L fib N' ✓aS s�, s►� le. �d�C . Town of Barnstable °FSHE T Regulatory Services Richard V. Scali, Interim Director B" MA3& . ' Public Health Division 9� 039S. 10g' �Ec ram' Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Homeowner Certification Form for Alternative Systems Property Address: 706 f &4 Assessor's Map\Parcel: .26k 61,zr/ ,07(� Property Owners Name: ptie In accordance with Massachusetts DEP alternative system approval letters, the following certification information is required by the Owner of record. The Owner of record must place an "x" in the applicable box next to each line certifying the information. Yes N\A lJ ❑ I have been provided a copy of the Title 5 I/A technology Approval letters. (15 page Standard Conditions letter and the specific technology letter) ❑ I have been provided with the Owner's Manual IJ ❑ I have been provided with the Operation and Maintenance Manual ❑ 13 For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10) and the Approval ❑ L?/For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5) P< ❑ If the design does not provide for the use of garbage grinders, the restriction is understood and accepted ❑ Whether or not covered by a warranty, I understand the requirement to repair, replace, modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the environment, as defined in 310 CMR 15.303 agree to comply with all terms and conditions above. operty O printed name Property %ers Signature Date Note: This form must be submitted along with the septic system disposal works permit application for all I\A systems including new construction, repairs\upgrades, with and without aggregate (stone) and with conventional design criteria or credited design criteria. Q:\Septic\lAhomeownercertification.doc TOWN nnOF BARNSTABLE LOCATION�3,� D��_�u/y1 /Gpl4f� SEWAGE#? Ol 2 J8 VILLAGE � ASSESSOR'S MAP&PARCEL ZGg a 76 INSTALLER'S NAME&PHONE NO.S08' SEPTIC TANK CAPACITY IS1140 LL LEACHING FACILITY:(type) ,/ 10 l�0"'6(;M (size) IO X Y NO.OF BEDROOMS' -OWNER Agror-to ec:eN4 G 'PERMIT DATE: `l —7 COMPLIANCE DATE: 7 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) J� Feet FURNISHED BY,4'�/ 'a /, � a Y - f' r ' V - g %41 lei Y H s cc °° o= b°. ' �N M M I ii n ii 11 Town of B instable. P# Department of Regulatory Services € Public Healhi Dividon Date KUL ssJy. 200 Main Street.Hyannis MA 02601 Date Scheduled J ` s i Time Fee Pd. ,foil Suitability Assessment for Sewage Disposal Performed By. ! Witnessed By. i LOCATION&GE NEI&L WORMATIO Location Address'. Owner's Name �QC(GL ��Y � . ,/,a Address /—)-7�" lol Assessor's Mapmvicel: Z 6 7 6 Engineer's,lame//NEW CONSMUtON RBPAQt Telephone# • � Surface Stones � S'4'C/ •r,����sf y�� Land Use R1 Slopes(96) S d Body _It Passible Wet Ana Distances from: ripen Water � ft Lhinidng Water Well Drainage Way ft. Property line ft Other fi: s of lot,exact locations of t tholes&pere tests.locate wetlands in proximity to holes) SKETCH:(street name,dimensiod -7 PTI r 'y �Cc'lL/ Parent material(gedlogie) Depth to Bedrock � - Depth to Gronndwalor: Standing Water in Aote: •l�lf Weeping tMm Pit Patx Estimated Seasonal high Groundwater D ON FOR SEASONAL MGH WATER TADLE Method Used Depth abaerved admding obL hole: In. Depth tO sell Molts= !n. D tl;w, ing from side Of .hole I in, prtpundWhler A uetmMt index Well#� Rading Dati Index Well levll r A�.tbetoF Ad;.tltatndWaNtLevel. 13 PERCOLATION TEST Dato om Observation I Tlnte at 9" Hole# �`�--- � ....._._.-- Depth of Pelt Start Pre-soakilme.CYO — -- ! End Pro soak r Rate MinJlnch /NAA//(/ Additional Testing Needed(Y/1V) Site Suitability Asscpsment: Site Passed I - Site Failed; .T._ Ori!doat.•.Public Health Division Observadol 1161a Data To Be Completed on Back----- ***If percola ion test is to be conducted within 100'of wetland,you most first now'the Barnstable C44servation Division at least one(1)week prior to beginning• DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other .Surface(in.) (USDA) (Mansell) Moffmg (Stutti ,SWuesr Willtlets. r 1¢ ` /v•V, / 2�y c DEEP OBSERVATION HOLE LOG Hole# Depth from! Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. D �i G DEEP OBSERVATION HOLE LOG Hole# Depth from' Soil Horizon Soil Texture Soil Color Soil • Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ' DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color blob Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Omni) Flood Insurance Rate Mal); Above 500 year flood boundary No— Yea Within 500 year boundary No✓/ Yes Within 100 year flood boundary No v Yes Death of Naturally Occurring Pervious Material Does at least four feet of 02MMUy occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? j If not,what is the depth of naturally occurring peAvious,material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,a rose and experience described in 3.10 CMR 15.017. Signature Date��_r`� Provide Riser over D-box NOTE:All components to be marked with NOTE:To prevent breakout,final grade j; F.(Full) to within 6"of final grade magnetic tape or similar prior to final cover. of EL.96.24 to be carried out a EL. 100.77 (Cover to-be watertight) minimum 15'beyond edge of leach F.G. xis 99.4-100.0t F.G. EL:99.43t F.G. EL:98.3t Maintain Min.2%slope over leach facility to prevent ondin facility. Existing �. p �' p g F.G. EL:98.33t Install risers w/covers over inlet and Clean Fill per Title 5 Specifications Inspection Ports within 3"to grade Existing Main Line a outlet to within 6"of final grade (Cast Iron) L=13 (Access Covers min.20"diam. per Code) ' Naturally Occurring Suitable Sand 0"Per Un t R eat Length EL.98.44 Cast Iron to 4"SCH 40 PV L=75 ;; L=10' Top of Unit/Breakout EL 96.24 • 4"SCH 40 PVC a (4"SCH 40 PVC @S=7.3%(2%MIN) to• 14• @S=1.4%(1%MIN) s' @S=2%(0.5%MIN) 0.89' Eff.Depth EL.97.23 EL.96.0 :<: Install Gas Baffle EL.96.17 "'`"" """'` EL.97.48 PROPOSED DB-3 EL.95.8 Use 12(2 Rows of 6 units) Arc 36HC H-20 with <`. H-10 DISTRIBUTION BOX End Caps without Stone in a Trench 9 96' Configuration set 6'apart (Install PVC Inlet&Outlet Tees) Wmore than for levelness if SEPTIC SYSTEM PROFILE (30.5'x 2.87'x 0.89' Each Trench) PROPOSED 1500 GALLON more than one outlet H-10 SEPTIC TANK EL. 4.95 (Precast Concrete) ADDITIONAL NOTES N.T.S. Bottom of TH-1 SOIL LOG 1. Contractor to confim soil suitability prior to installation. Contact BOH and Design DESIGN CRITERIA Sanitarian in the event of varying soils from original soil test. Number of Bedrooms: Existing 3 Bedrooms SOIL EVALUATOR: AMY VON HONE, R.S. S.E.#2517 INSPECTOR: DON DESMARAIS, R.S., BOH 2. Failed cesspool to be pumped and removed for placement of proposed septic tank. Soil Type: Class I DATE: JUNE 17,2013 1:30 PM Design Percolation Rate: <2 min/Inch in C1 Horizon PERCOLATION RATE: <2 MIN/INCH IN CJ - 3. Water line to be sleeved at any sewerline crossings and within 10'of any septic PERMIT#: 14035 components, as needed, per Water Department requirements. k. Daily Flow: 110 G.P.D./ Bedroom x 3 =330 G.P.D. TH - 1 TH - 2 4. Septic Tank and Distribution box to be placed ion 6" crushed stone or compacted, level Design Flow: 330 G.P.D. (Min. Required) EL.98.12 EL.98.12 base' Garbage Grinder: Not Allowed FillA sandy Loam FLOOR PLAN Leaching Area Required: (330)/0.74 = 445.95 S.F. 9" 97.37 8„ 10YR3/3 97.45 N.T.S. Septic Tank Required: 330 G.P.D.x 200% = 660 G.P.D Sandy Loam Loamy sand Minimum 1500 Gallon (Proposed) 10YR2/1 10YR4/6 Use 12 Biodiffuser Arc 36HC Units (H-20) in a Trench Configuration: 15" 96.87 27" 95.87 B Bedroom 1 B Effective ath Kitchen 2 Rows of 6 Units Each with End Caps, Stoneless: 30.5'x 2.87'x 0.89' Sandy Loam Perc C1 Effti Leaching Area: 10YR5/6 @ Coarse Sand g 24" 96.12 45"Bc m 2.5Y5/6 tl C1 Il 7.79 SF/LF x 5.0'/Unit= 38.95 SF/Unit (Per DEP General Approval Letter) Coarse Sand diving 445.94 SF/38.95 SF/Unit= 11.4 Units. Use 12 x 38.95 SF/Unit=467.4 SF 2.5Y6/4 Den Room Design Flow Provided: 467.4 SF(0.74) = 345.87 GPD. Open Entry PERC RATE:.<2 MIN/IN.(C L Horizon) 1st Floor 133 OLD TOWN ROAD, HYAN N IS, MA 24 gallons @ 3:51 m nutes V H PREPARED FOR: Bath associates Patricia Greene 158" 84 95 120" SEPTIC SYSTEM DESIGNS 88.12 1275 Valley Road No Groundwater Observed No Groundwater Observed' 320 Cotult Road ( Santlwlch,MA 02563 (o)508.833.0041 Mason, NH 03048 (c)508.274.0074 Bedroom 2 Bedroom 3 Surveyeng I I,Amy L.von Hone, R.S., hereby certify that I am currently approved by the DEP pursuant to Terry A. Warner.P.L.S. 310 CMR 15.017 n n that the above 01 to conduct soil evaluations o e analyses has been � 22 eon Road performed by me consistent with the requirements of 310 CMR 15.017, 1 further certify that Worweah, MA 02645 DATE REVISED SCALE SHEET NO. I have successfully passed the Soil Evaluator's Exam on November,1994. 2nd Floor ,- (508) 432-8309 n = 06/17 13 2- ?0 2 0f 2 n GENERAL NOTES: wes Main street_ ASSESSOR'S MAP: 268 t j PARCEL: 076 Pine Street 1. VERTICAL DATUM: Assumed REFERENCE: Old Town Road L yOUt I 2. MUNICIPAL WATER Is AVAILABLE. LOCUS FLOOD ZONE: C Town of Barnstable 3. SCHEDULE 40 PVC PIPE TO BE USED THROUGHOUT SYSTEM #250001 0008 D (7/02/92) UNLESS OTHERWISE NOTED. �a me Road x 98,41 0�, 4. ALL PRECAST& PLASTIC UNITS TO CONFORM TO Cray 9759 AASHTO: H-10 &20 O,d T x x 50.71 I 10.97' x . 5• PIPE PITCH-1/4" PER FOOT UNLESS OTHERWISE NOTED. Lots 21A&21B 6. ALL CONSTRUCTION DETAILS TO BE IN CONFORMANCE WITH MA GurN0aW q °�� c 1 9,873t S.F. ENVIR. CODE (TITLE 5)AND LOCAL REGULATIONS. 0.23t AC. 7• CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO LOCUS MAP N.T.S. I 21' CONSTRUCTION. /J 30.5, TH,:L LEGEND: 00 x 98,33 6' N ( �— 99—�- PROPOSED CONTOUR NOTE: Pump and remove failed cesspool for x 99,1T septic tank installation. �q 1.11 99 PROPOSED SPOT GRADE C_ RESERVE AR �C0 40 EXISTING CONTOUR / 20' 25, - T�H-2 - 30.23'-" EXISTING SPOT GRADE // � 17L_ R SER E q_"_ \ x�97.74 TEST PIT A 3 ——�Benchmark set: ; Jcp� 9 98,40 x 98,46 Q ® EXISTING WATER SERVICE Right corner conc. step / ,� Shed 3 ' 4- 0 EL.= 99.59 (Assumed) 98 4 m \` o ©Xo WORK LIMIT LINE rn00 � Q J1/ x 98,93 0 w �� OF .Mqf �� OF M9ff p t� Garage i x 99 8 Stone., ti x 98.07 0� AMY L. �, o TERRY G� o VON HONE y o WARNER H Z 98.45 �pr►ve:' x g �^ a ANN x x 99,43 Op 98, 5 p O J No. 1068 ti J No. 38721 -P O x 99.69 9 ,220 100,00 99.97 99.77 4.98 l x13' � . ' 100,00o , KD 0 J Patio" x 97 x �7e -� #133 NOTE: This plan is to be used for septic system 99.43 TOF=100.77 D l purposes only and is not to be considered a property 1 / (Assumed) N .�,�� line survey. Property lines are approximate. (. 99.10 Q - TWIN-I8IN-°AKS o co' x 98.62 �8 76 x 99.37 99 6, - �S .94 9 oFF LPREARTED LD TOWN ROAD, HYANNIS, MA 1FT=°AK 99,37 i V H 9q.66 FOR: x 98,25 / °ti 99.8 associates Patricia Greene A' SEPTIC SYSTEM DESIGNS ich J TWIN-1FT=❑AK 1275 Valley Road nd / 04099,77 78 23' U P/ -1/2 32o cotuR Road 99, S(o)508.833.0041ndwich,MA 3 Mason, NH 03048 99 3< 99.36 (a)508.274.007a x 99,37 99.13 Surveying by: Terry A. Warner.P.L.S x 99,98 Harwich, MA 02645 REVISED SCALE SHEET NO. (508) 432-8309 x 99.59 3 1" = 20' 1 of 2