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HomeMy WebLinkAbout0286 OLD TOWN ROAD - Health .�286O1�d yTbwn Roa'd IkJ I6 TOWN OF BARNSTABLE LOCATION 09(0 CA8 AQ,,5.N�. SEWAGE# sal "74 VILLAGE arm tr ASSESSOR'S MAP&PARCEL Q') I ors L4 c r . INSTALLER'S NAME&PHONE NO. c�LC7 aCjk-f 0M SEPTIC TANK CAPACITY LEACHING FACILITY:(type). y C C,A— [r} 1® (size) 1 X ti NO.OF BEDROOMS A:. OWNER ii PERMIT DATE: 1 aZ U COMPLIANCE DATE: ;t U + 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 ice kcv, 00 sa � L i C-f, t� Y r No. r Fee f&THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppliCation for Mispo8al *pstrm Construction Permit Application for a Permit to Construct( ) Repair�) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. C` (A. Owner's Name,Address,and Tel.No.Assessor's Map/Parcel r b[a \® `'` bk10\-C_ / Z�­'l—CA% rl c.<- L-f Installer's Name,Address,and Tel.No. D er's Name,Address,and Tel.No. \A1 Okkl �f�crM.liti�� f� c� iV� CCi3 �ur.t4.t�.!� �•�es �C� e �� c�•. c.,nn Type of uildmg: 0 06e Gj 9'0''1 614 l_ Dwelling No.of Bedrooms Lot Size [>_ ' b sq.ft. Garbage Grinder WO Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ,-3 6 gpd Design flow provided ?(j!, T:Z gpd Plan Date G Number of sheets 9c Revision Date Title Size of Septic Tank l!j:'bfj JA 11L) Type of S.A.S. I`ia U Q {�p�C E2 ® e;et O•4 It Description of Soil Nature of Repairs or Alterations(Answer when applicable) � �e, r�r-_62 ��{SS�� L. �,!V" a(ate 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�thisoard of Health. Date / 1 / Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued �!� S No. ✓?—r' ! Fee / s Yp THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: C,, t* Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4plitatiou for Disposal Opstem Construttion Permit oe Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System 4Z Individual Components Location Address or Lot No. QL Owner's Name,Address,and Tel.No. Assessor's Map/Parcel (o� y��t n t S J ate'P�^ Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. \►3 Okd Cn1JCL(1 �r--A1.^./%1)" o CCU Typ -• p �+i E+ae• P A4 s .�.f CIS � `"Ad � �Y� v 4 6MUT • 9.. 4efBd oG —• Dwelling No.of Bedrooms Lot Size IG b D b sq.ft. Garbage Grinder(NQ Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures s Design Flow(min.required) , gpd Design flow provided?4 Ci. _�' gpd Plan Date (n, C C� a 'Number of sheets Revision Date Title 5 Size of Septic Tank 1 44''ElU (tom k-c.r-V. Type of S.A.S. D ewxz ? ` G �a a 1 14 I to +: Description of Soil d _ i s f Nature of Repairs or Alterations(Answer when applicable) ��n I r t__x 4 w Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in .r accordance with the,provisions of Title 5 of the Environmental Code and not to place the system in operatiori until a Certificate of Compliance has been issued by this Board of Health. ..-- " • Signed 0 ).2 0 ' ,; ' =''�y Date Application Approved by 1 Date ._ r Application Disapproved by Date for the following reasons Permit No. DaQZl ---- Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance � THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed_ ( ) Repaired( Upgraded( ) Abandoned( )by f ")f't�_i A i.& V r*^ at 3 S-(A i31 no ��.��, (� � y.�4�c��,`�, has bee constructed in accordance p Disposal Y Q T-40 with the provisions of Title 5 and the for Dis osal System Construction Permit Now ,. d�ted � Installer (� c 9.�- Designer w)Q M,.�)G,L�,. , Jr 4 " #bedrooms., Approved'desigrrflnw a W( o gpd �, . f - - The issuance of this pe/r'mit shall not jbe construed as a guarantee that the system will funcction as designed vuvDateInspector f 4� R 11y~� �`•, -...•.-- _ - _ -• - _ - -_ _ _ - ---- ----------- - No. . Fee THE COMMONWEALTH OF MASSACHUSETTS G% PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS <�o- Misposal 6psteut Construction 3permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at ) (� '� r} ��,�a e- �. n e\t and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio//n��murst/be completed within three years of the date of this ipermit. Date t I t Approved by, . y t• Town of Barnstable .4VE ,o Inspectional Services Public Health Division `T ° Thomas McKean, Director .( Ar�ora 200 Main Street,Hyannis,MA 02601 Office: 508-9624644 Fax: 508-790-6304 y.a Installer & Designer Certification Form Date: 20 Sewage Permit# (� �.� 49sessor's Map\Parcel Designer: bg vA Q. Co1/1�a n awr- Installer: �.�--1 r••► '1'rc--� Address: tS S beer P-r4e j( Address: �2 v vy �C Oz.to3 On l { vZ� SJ C- -\/( _ was issued a permit to install a (date) (installer) septic system at 2 a Old TOW" based on a design drawn by LL (address) pv1 d� (6p uj )gitowr, ZS dated dune q, z aZ.O / (designer) I 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. Strip out (if required) was inspected and the soils were found satisfactory. 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. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in co ith the to rms of the RA. approval left (if applicable) � �•��'�or Millss� c oAvifl yG� - D. COUGHANOWR Installer's Signature) No. 1093 0 ISTt `1 ( esigner's Signature) 111 (Affix Designer's tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. WoaldeptMEALTRSEWER conneOSEPTIODesigncr Certification Farm Rev 8.14-13.DOC SOIL TEST L O ' ' D[ESION O A LLC UUL A T I O aO SOIL EVALUATOR: DAVID D. COUGHANOWR, ASE #461 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD WITNESSED BY: DONALD DESMARAIS, HEALTH DEPT. TEST PIT NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS PERC AT 58 in - 2 MIN/INCH IN C SOILS INSTALL NEW 1500 GALLON SEPTIC TANK. ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DISTRIBUTION BOX: INSTALL UNIT DEPICTED BELOW. 42$Q INCHES HORIZON TEXTURE (MUNSELL) MOTTLES 0-7 FILL SOIL ABSORBTION SYSTEM: 7-12 Ap LOAM 10 YR 3/3 NONE FRIABLE THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES 12-40 Bw LOAMY SAND 10 YR 4/4 NONE FRIABLE 39.47 PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. 40-132 C MEDIUM SAND 10 YR 514 NONE LOOSE 31.80 THE 'L' SHAPED LEACHING GALLERY DEPICTED CAN LEACH: TEST PIT 2 NO GROUNDWATER ENCOUNTERED BOTTOM AREA = 12.83 (16.5 + 8.5) = 320.75 sq. ft 2 MIN/INCH IN C SOILS SIDEWALL AREA = (16.5+12.83+3.67 ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER +8.5+12.83+21.33)x2 =151.32 sq. ft. INCHES HORIZON TEXTURE (MUNSELL) MOTTLES 42.60 TOTAL AREA = 472 sq. ft. 0-5 FILL FLOW CAPACITY = 0.74 x 472 = 349.33 Sol/dog 5-10 Ap LOAM 10 YR 3/3 NONE FRIABLE INSTALL THE 'L' SHAPED LEACHING GALLERY AS CONFIGURED 39.60 36-1 10-3 2 C MEDIUM SAND 10 YR 5/4 NONE LOOSE Bw LOAMY SAND 10 YR 4/4 NONE FRIABLE BELOW. FLOW CAPACITY = 349.33 gal/doy WHICH EXCEEDS 31.60 g y THE 330 al/da REQUIRED FOR A THREE BEDROOM DESIGN. 00 (GALLON SSEPT7C� TATANK �O�L� Q��OG�p 1��0NN 15 SS Y S� %EM,,, CONSTRUCTION DETAIL 3DIMENSIONS & DETAILS s USE SHOREY,PkCAST 500 GALLON LEACHING DRYWELL USE SHOREY ST-1500.__H:-10 12.83 ft INSTALL TWO DRYWELL w A UNITS AS SHOWN I in NOT ., $.5 ft WITH FOUR FEET OF TAPER `S TO J STONE ALL AROUND. SCALE ° 00 N MARK INSPECTION x OD RISER WITH 5 ft— w MAGNETIC TAP. O a 8 in + DRYWELL UNIT o ;, { �(� 21.33 ft A /c ft_ �` 500 GALLON DRYWELL 6 /n INSTALL ONE INSPECTION RISER DIMENSIONS TO WITHIN THREE INCHES OF & DETAIL _ FINAL GRADE &INDICATE INLET OUTLET _ LOCATION ON AS-BUILT COVER COVER .� `� USE 33 H-10 3 IN DROP r FLOW LINEp� in UNIT FRM BUILDING , 10 in 14 TO E 48 in p-BOX - ------ --- p�0/ �� LIQUID GAS 102 ;n LEVEL BAFFLE CROSS SECTION VIEW (SECTION A-A) - _;: _ INSTALL AN APPROVED GEOTEXTILE b in STONE BASE FABRIC OVER STONE SEPARATION BETWEEN INLET & OUTLET : .. TEES NO LESS THAN LIQUID DEPTH CROSS SECTION VIEW 2B 3/4 in TO o EFFECTIVE® 3/4 m TO 2 in GRAVEL, tl 1/2 in GRAVEL in o DEPTH e INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE 48 in 58 in 48 in STARTING WORK. -ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM 154 in @ REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). -INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND I UTILITIES BEFORE EXCAVATING FOR SYSTEM. -ECO-TECH RAPID RESPONSE RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES & APPLIANCES, AND PERIODIC PUMPING OF THE SEPTIC TANK. c -SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. \� DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. G L O W p 0 F 0 [ C TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO BE 4 in SCH. 40 PVC EL = 46.54 +— b in OF FINAL GRADE AND TO PITCH AT 1/8 in/ft MIN 43.0 D-B0 MAX USE H-20 MTAL TEE 40.0 42.80 1500 Off° LLON o 00000° ao�agaa o° PRECAST o°000°u°S o ono°o00 EXISTING o 42.00 0000°00000o DRYWELL o°°o°oo- -. ��p��� TANK 39.38 °oao oo°oo a°o 42.25 REFER TO DETAIL BOX S6 in SODLL QBSORPTM + 39.55 BASE 39.25 M 2n� 6 in STONE BASE IF NEW S U STEM —REFER TO o 24 ft 20 ft 5-12 ft DETAIL BOX 37.25 LO NO GROUNDWATER BELOW MOTTLING OBSERVED SEWAGE DISPOSAL SYSTEM PLAN 28 OOLD TOWN ROAD HYANNIS, MA JUNE 5, 2020 ETE-4460 PG 2/2 141 GARB O� Q;� GIS DA "U G OT eELEVATION OWED 4654 OF FOUND P .P E q D o 100.000 ft I LOOT I +� A ER A = 70000 Sf+- v PLAN BOOK 23 PAGE 125 I G ASSR MAP 247 Pa 164 1 'Cry , I THIS IS A 45 COLOR OIIQ 1 M � Q PLAN Q� V USE COLOR PLAN ONLY FOR INSTALLATION FULL DETAIL IS BEST VIEWED IN ING FULL COLOR / 1 1 44 LEGEND PI\'45� N y SEPTIC COMPONENTS w �G o• 1500 GAL E S o SEPTIC TANK ® g /C0 IPI N O EXISTING l MINIMAL LEACH PIT/ GRADING �— , PROPOSED CESSPOOL 44 I 10 ft DISTRIBUTION BOX® 1 20 in OAK TEST PIT PROPOSED SOIL EXISTING CESSPOOLS TO / \ I ABSORPTION BE PUMPED. COLLAPSED 1 SYSTEM AND FILLED. -SEE DETAIL 43 ON BACK 61.116 ft — 43 j, p � U�j p V §L�,0T§ES . • WATER LINE PLAN , WATER GATE 0 GAS LINES SCALE: I in = 20 ft OVERHEAD WIRE-(a- 0 20 40 e O 10 20 ° e PRINT ON 8-112 x 14 in 0. PAPER FOR PROPER SCALE THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM DEPICTED ON IT. FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING PLACEMENT OF ADDITIONS, SHEDS. FENCES OR SWIMMING POOLS, OWNER A --P SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. "o i .♦ SEWAGE DISPOSAL ems . � o edmo ma 9• ��I+a R c�p"-\k\ V,/"SS9 `SN pF 1�SS ' ` ` SYSTEM PLAN DAVID 9OyG -TO SERVE EXISTING DWELLING s o SARAH MARTINEZ COUGHANOWR � u COUGHANOWR N a a� P ®a'j a*ram°° ® No. 1093 No. 461 " 3 & )O S E P H O T O O L E OWNER(S) OF RECORD 9 , � SFGIS7 s�PPRO`1E� -_ _�(° 286 OLD TOWN ROAD 7m q P q P� - HYANNIS, MA CUSS-i°©R rw m `° 155 Geo Ryder Rd S PROPERTY ADDRESS ��•°jd" ° Chothom, MA 02633 HYANNIS. MA.%? Dovidcou@HotmoiLcom DATE, JUNE. 5, 2020 L O C U S M A P 508 364-0894 PG. I/2 .JOe# ETE-4460 necoe''' TOWN OF BARNSTABLE LOCATION � d l� of o _t og),v Z SEWAGE # a✓s VILLAGE NNtJ ASSESSOR'S MAP & LOT �� INSTALLER'S NAME&PHONE NO. d b l v ®ti ���� C - (�7 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) . 'Z XL K (size) NO.OF BEDROOMS_ BUILDER OR OWNER `: e-ue JDcJI-G e PERMITDATE: COMPLIANCE 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 .+ � �I. w�/� /� �.� J � C� � � - r � � ��� ! � • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'bo � 286 Old Town Road � Property Address iV Eileen Kauth Owner Owner's Name information is required for every Hyannis ✓ Ma. 02601 04/02/2016 page. Cityrrown State Zip Code Date of Inspection w 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 Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections Q Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 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 2L-_-_—_ 04/07/2016 In pector'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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �qw vs Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�' 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is y required for every H annis Ma. 02601 04/02/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if 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•3/13 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 ,••''y 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 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 of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 page. Citylfown 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): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °,M .•'" 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Fall2015 Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpa) 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 - 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: Inspector Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: Apx. 400 gallons gallons How was quantity pumped determined? Drivers Est. Reason for pumping: Cesspool 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): Sins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 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 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis annis Ma. 02601 04/02/2016 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•3/13 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 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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.): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: One ❑ 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 the time of the inspection the overflow was dry and there were no signs of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration One round Depth—top of liquid to inlet invert apx. 4 feet Depth of solids layer 1 Depth of scum layer 1 Dimensions of cesspool apx. 6 x 6 Materials of construction block Indication of groundwater inflow ❑ Yes ® No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments aM ,••''y 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •' 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 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 r� •J ^J t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 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: 13'6" plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole a five foot deep hole in the dry overflow cesspool to show five plus feet of seperation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 286 Old Town Road Property Address Eileen Kauth Owner Owner's Name information is required for every Hyannis Ma. 02601 04/02/2016 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file j 4 6^ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17