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HomeMy WebLinkAbout0147 OLD TOWN ROAD - Health l 4.7 Old Town Road 13yannis A= 268 - 077 TOWN OF BARNSTABLE u,oS LOCATION NI I ()LP —to W n/ A, Q SEWAGE# I .VILLAGE P--f4/g n+l S ASSESSOR'S MAP&PARCELlw —©Tl INSTALLER'S NAME&PHONE NO. (5-0 s 117 f 2 g Fj C, SEPTICTANK CAPACITY 1 0 o cam' LEACHING FACILITY (type) (size) NO.OF BEDROOMS 3 OWNER Z) IAt J �i w?& S PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: „-r '40 Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J t% 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 c 2 3 No. O �✓ Fee Q THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplication for �Biqwt �&p!5tem Construction Vermtt Application for a Permit to Construct( ) Repair('If Upgrade( ) Abandon( ) ❑Complete System 2J Individual Components Location Address or Lot No. 0-1-1 O LID -R'A n1 Q-o nd Owner's Name,Address,and Tel.No. ►i-4Ar4N6 VVA 3RtpN L,-n►OCI1 S (5-0s�7�1 1` -1 OLD TAwN Assessor's Map/Parcel20 o 17 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. D A-VID j, 3vtu4rc 3:o /w1rN `7-4-m- - _ Yp e 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 t O oU &'Ca-L-p N5 Type of S.A.S. (o'X(o' P Rc C1n,; r 2, ; Description of Soil Nature ofRepairs or Alterations(Answer when applicable) -C DLACC Ou i 1-�F7 LtN1C raorn T/- N(_ TO TjWX. IzeAlA-C .J-) t5t�YLcQJ71,s�f ee Y +2oM V'o A ,O I-r . 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. igne zMY0 Date 11 3 0 Application Approved Date Application Disapproved by: Date for the following reasons ��y�, IC-Al—No. r� � '"q(,5 � Date Issued f No.. W O�`�� Fee Q Q THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' t PUBLIC HEAILTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0[ppYication for �Bizponl :�)p!tem Cow5truction Permit Application for a Permit to Construct( ) Repair(✓) Upgrade( ) Abandon( ) ❑ Complete System Zindividual Components Location Address or Lot No. i`I-1 0 l O TO vJ N 2 o a) Owner's Name,Address,and Tel.No. 1} IatJN�S M� a�iGN IRNOC 2 S (SU��"1S� 2 5 S2 Assessor's Map/Parcel 20 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �pV17 T, ^_,a N 5%QIZ�' Q LJk wa'x2. �9S-2duu Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( I ) Other Type of Building No.of Persons Showers( ) Cafeteria,( ) 3 Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank\�,G y O E a st.D 1.1 5 Type of S.A.S. (o X P a r C-AS-c 7. i Description of Soil f Nature of Repairs or Alterations(Answer when applicable) �F D LAC(:7 O j iZ�i t.I N F �C-C)to -T ru tc 1 o -D 2X) !(zt--0 LA 0 n I ST 12 (W17 o N �FPw c 1 tit �n o Date last inspected: �. ii 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 th' Board o Health. / I igned \l i G� G��`1/ � Date 11 ( G Application Approved by Date �( Application Disapproved by: Date for the following reasons Permit No. p ." (r Date Issued /1 3 cr� {` - --.. _ _ - THE COli MONWEALTH 017'MASSACHUSETTS`,; f' BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( v) Upgraded ( ) Abandoned( )by 3t_gC w a-, at 1`� U c.D /J P P 4—I ANN►S has been nccon$truct d in 'ecordance with the provisions of Title 5 and the for Disposal System onstruction Permit No.� r1 `+'r dated Installer�W+� J• �u2/�l�F �gt.Ut�0� �'Z Designer y III #bedrooms Approved design flow gpd f, The issuance of this permit shall(not be c wnssttr�ued as a guarantee that the system �('1L-u eti/o�n/as dees�igneo/// �ff%`t" Date 1 r"i ( Inspector /t A!ll l.✓t f - - -- ---------- --- --- i No. � [ l�,�j�^ _`_ .,._ . . • � .Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS lizpo5ar �p.Wm Construction Permit Permission is hereby granied to Construct ( )` Repair (1-1) Upgrade ( ')� Abandon ( ) System located at t 41 0�_n t o t-Ji tco 4.0 N r Ate N t S /WA 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)mustcompleted within three years of the date of this pe ibe rmit. Date 1 ` Approved by f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Volun tary ry Assessments 147 Old Town Road Property Address Owner Brian Landers s Name information is Owner required for Hyannis every page. Cityfrown MA 02601 10/24/2008" State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms May not be way' Y altered in any Important: When filling out A. General Information forms on the computer,use only the tab key 1• Inspector: to move your cursor-do not Brad J. White Use.the return Name of Inspector key. Bluewater Company Name ` 350 Main Street Company Address West Yarmouth City/-rown MA (508 775-2800 State Zip Code Telephone Number License Number - B. Certification . , I certify that I have personally inspected the sewage disposal system at this address and at the information reported below is true, accurate and complete as of the time of the inspection. T,he inspection I was performed based on my training and experience in the proper function and maintenan a of on site n sewage disposal systems. I am a DEP a Title 5(310 CMR 15.000). The system: pproved system inspector pursuant to Section 15.340 of ❑ Passes ✓❑ Conditionally Passes ❑ Fails i I ❑ Needs Further Evaluation by the Local Approving Authority Inspectors ' n re 10/24/2008 Date 1 The syste 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 i Pp 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 shout and copies sent to the buyer, if applicable, and the approving authority. be sent to the system owner This report only describes conditions at the time of inspection and under the conditions of use it at that time..This inspection does not address how the system will perform in the same or different conditions of use. the future under I t5insp.doc•03108 l 1; Title 5 Official Inspection Form:Subsurface tal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 147 Old Town Road Property Address Brian Landers Owner Owner's Name information is required for Hyannis MA 02601 10/24/2008 every page. City/Town State ZipCode Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D - A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ✓❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent: System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: 1 I I I I— ✓❑ 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): { L✓J broken pipe(s) are replaced I ❑ . obstruction is removed t5insp.doc•03/08 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 iI i i Commonwealth of Massachusetts Title 5 Official In Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Old Town Road Property Address Brian Landers Owner Owner's Name information is - required for Hyannis MA 02601 10/24/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): distribution box is leveled or replaced ND Explain: Outlet line is schedule 20 pvc and cracked. Distribution box is corroded and needs to be replaced. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is 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 i f ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh f i 2. System will fail unless the Board of Health(and Public Water Supplier, if any) k 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 i 100 feet of a surface water supply or tributary to a surface water supply. i . 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 at e water supply well. i t5insp.doc•03/08 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 147 Old Town Road Property Address Brian Landers Owner Owner's Name information is required for Hyannis MA 02601 every page. City1rown 10/24/2008 State Zip Code Date of Inspection B. Certification (Cont.) - C) Further Evaluation is Required by the Board of Health(cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Cr iteria riteria Applicable to All Systems: You must indicate"Yes or"No"to each of the following for all inspections: Yes No i Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 0 ❑/ 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 Y day flow Required pumping more than 4 times in the last year NOT due to clogged or i ❑ obstructed I e s . Number of times pumped: Any portion of the SAS, cesspool or privy is below high ground water elevation. i ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. I t5insp.doc•03/08 { Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts MR Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M .147 Old Town Road Property Address Brian Landers Owner Owner's Name information is required for Hyannis MA 02601 10/24/2008 every page. City/Town i State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ Ly" 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. ElLJ 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 i ❑ ❑ the system is within 400 feet of a surface drinking water supply i t ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply . ❑ ❑ the system is located in nitrogen sensitive area (Interim Wellhead Protection Area IWPA)or a mapped Zone II of a public water supply well If you have answered "" es to any y 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 j regional office of the Department. t5insp.doc•03/08 tle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 YL 4 NN Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for VoluntaryAsses sments 147 Old Town Road Property Address Brian Landers Owner Owner s Name information is required for Hyannis MA 02601 every page. City/Town 10/24/2008 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 _ _/ p g mation was provided by the owner, occupant, or Board of Health El Were any of the system components pumped out in the previous two weeks? 12 ❑ Has the system received normal flows in the previous two week period? El 2 Have large volumes of water been'introduced to the system recently or as part of this inspection? ❑ -A El as built plans of the system obtained and examined? (If they were not available note as N/A) El Was the facility or dwelling inspected for signs of sewage back up? L� ❑ Was the site inspected for signs of break out? t� ❑ Were all system components, e*e6 i; y p �g 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 di sewage di sposal sposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: i ❑ 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 i approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•03/08 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 147 Old Town Road Property Address Brian Landers Owner Owner's Name information is Brian Landers MA required for 02601 10/24/2008. every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Unknown Number of bedrooms (actual): 3---- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Unknown— 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 Seasonal use? 10 Yes No Water meter readings, if available(last 2 years usage(gpd)): Utc ` L' A 617" �� p Sump pump? ® Yes No Last date of occupancy: Seasonal Use 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 I i Non-sanitary..waste discharged to the Title 5 system? ® Yes ® No f Water meter readings, if available: Last date of occupancy/use: i Date Other(describe): I t5insp.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 j i Commonwealth of Massachusetts 'Mmv Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 147 Old Town Road Property Address Brian Landers Owner Owner's Name information is Hyannis required for y MA 02601 10/24/2008 every page. City/Town State Zip Code Date of Inspection D.. System Information(cont.) General Information Pumping Records: Source of information: Approx 2 yrs 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 ❑.(N�] 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): Approximate age of all components, date installed(if known)and source of information: f ---� Unknown. No info at board of health.House is approx 35-40 years old. I Were sewage odors detected when arriving at the site? ® Yes No t5insp.doc•03/08 j Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 } V � Commonwealth of Massachusetts Title 5 Official_ c ai Inspection For p Subsurf ace Sewage _Disposal p System Form Not for Voluntary Assessments M 147 Old Town Road Property Address Brian Landers Owner Owners Name information is required for Hyannis MA 02601 10/24/2008 every page. City/Town. State Zip Code Date of Inspection D. System Information(cont.) Building Sewer(locate on site plan): Depth below grade: 1611 feet Material of construction: ❑ cast iron 0 40 PVC ❑other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): —'---- Building sewer is in good condition. Building sewer is in good condition. Septic Tank(locate on site plan): ---�- _ Depth below grade: 60 feet Material of construction: ✓❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: yearn Is age confirmed by a Certificate of Compliance? (attach.a-copy of certificate) �' Yes ® No ------ -=--- -- ----- - ` 1 Dimensions: ,000 gallon tank i Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 30 Scum thickness. .1/2" Distance from top of scum to top of outlet tee or baffle 91 1. Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 .. 'I , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments nts 147 Old Town Road M Property Address Brian Landers Owner Owner's Name information is required for Hyannis MA 02601 10/24/2008 every page. City/Town State ZipCode Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet baffle is in good condition. No evidence of leakage in or out of tank. Outlet baffle needs to be " replaced due to corrosion. Inlet and outlet covers within 5" below grade. Grease Trap(locate on site plan): Depth below grader feet Material of construction: ❑concrete ❑ metal ❑fiberglass 9 ❑polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I I 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 El polyethylene ❑ other(explain):_ i t5insp.doc•03108 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 . p i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 147 Old Town Road Property Address Brian Landers Owner Owner's Name information is required for Hyannis MA 02601 10/17/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ® Yes No Alarm level: Alarm in working order: Yes ® No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ® No C] Yes 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 is corroded and needs to be replaced. Box is 12 below grade and only has one outlet leaving it. Box needs to be replaced. i Pump Chamber(locate on site plan): Pumps in working order: ® Yes No Alarms in working order: - t ® Yes ❑ No I t5msp.doc-03/08 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System=Page 11 of 15 Commonwealth of Massachusetts - Title 5 Official lnsn''ection Form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments ants 147 Old Town Road Property Address Brian Landers Owner Owner s Name information is required for Hyannis every page. City/Town MA 02601 10/24/2008 State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: hd leaching pits number: --10- 1 @ 6'x 6' ❑ leaching chambers number: ® leaching galleries number.- ❑ leaching trenches number., length: ❑ leaching fields number, dimensions: overflow cesspool p number: El innovative/alternative system I Type/name of technology: i Comments (note condition of soil, signs of hydraulic failure, level of ponding vegetation,etc.): , damp soil; condition of ----of Soil is dry. No signs of hydraulic failure. Vegetation is normal. No ponding. Leaching pit is 5"below r i grade. Pit was dry at time of inspection. Stain line indicates 3- " 9 of separation.-------------- i i r I t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 I Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 147 Old Town Road . Property Address Brian Landers Owner Owner's Name information is required for Hyannis MA 02601 10/24/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration - Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ® Yes No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids f I Comments(note condition of soil, signs of hydraulic failure, level of p etc.): onding, condition of vegetation, i 1 I i i i` i 15insp.doc•03/08 i 1— Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 f I r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 147 Old Town Road Property Address Brian Landers Owner Owners Name information is required for Hyannis MA 02601 . 10/24/2008 every page. CitylTown. State Zip Code Date of Inspection D. System Information (cont.) 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. ll" 1Li-I 4 Q3 33 r 3 �`-� -�, LIP . i I I f I 1 r i I t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 7 Commonwealth of Massachusetts = W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 147 Old Town Road Property Address Brian Landers Owner Owner s Name information is required for Hyannis MA 02601 every page. City/Town 10/24/2008 State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑✓ Check Slope 0 Surface water 0 Check cellar Shallow wells Estimated depth to high ground water: —go- 130"+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: --Mo. MIW 29/Zone C/Level 87/Adjustment 48" You must describe how you established the high ground water elevation: ----- Bottom of the leaching pit is 77" below grade. If you add the required usgs adjustment of 48"brings the total to 125". Performed an augeer hole to a depth of 130"with no indication of groundwater. This leaves an additional 5"of seperation. I i i i t5insp.doc•03/08 j Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 ' I 1 e � © h a q T �C 3 co o - � o I f i ; r ` 1 I i ;