HomeMy WebLinkAbout0010 OTIS ROAD - Health (2) 10 Otis Road
Hyannis
A = 310 - 112 .
TOWN OF BARNSTABLE
LOCATION 10 0T.2 S SEWAGE#
VILLAC-r ,E f ua�,�;s ASSESSOR'S MAP&PARCEL 3/0 - I I Z
R'SNAME&PHONE NO. 34 13 EAea,%)aA10n q I I - 06S3
NK CAPACITY /S00 90-)
LEACHING FACILITY: (type) ?PcnQAr.S (2) (size) Z x 3 x 33
NO.OF BEDROOMS
OWNER Rau A
PERMIT DATE: 77-Z 8 - IS- 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
Ai - 2z
131
A2 ' ZI'G i
(32 '2 3 ' 4 l 0
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No. Z9?- Fee /&.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pphLation for 16po al �p6 M Construction 3dermit
Application for a Permit to Construct( ) Repair( ) Up a Abandon( ) ❑Complete System ❑Individual Components.
Location Address or Lot No. /Q /S O er's Name,Address,and Tel.No.
Assessor's Map/Parcel tJCp3I D _�>Qe,1/1 Z
Installer'dam e Address,and Tel.No. . Designer's Name,Address,and Tel.No�V0jt.0n . -407-D(as3 JNV10 A060Yl
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures q
Design Flow(min.required) ��[� gpd Design flow provided 357 gpd
Plan Date -7 11-7 k S Number of sheets I Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) l colk
L21)
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 Boa of H h. r
d Date Z$l l
Application Approved by Date
Application Disapproved Date
for the following reas ns
Permit No. 7li gZ Date Issued /Zl
No.
y-; THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
"'PUPLIC HEALTH DIVISION - TOWN & BARNSTABLE, MASSACHUSETTS
Jx
Rppficatiol for Mispo ar-- Asp In Construction Permit
Application for a Permit to Construct( ) Repair Up, a I Abandon( ) [:]Complete System ❑Individual Components
Location Address or Lot No. /0 'f I S /20 O er's Name,Address,and Tel.No. / a Q
Assessor's Map/Parcel 316 -pGeiel/I Z , Qyrn�n(�Z j� Mc' "/-- � " !S7 —o� 7
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Cx(4VO-06n 509- ti77- ,06t?3 D6V/3 A050-r't sv�-�3 - z177
1
Type of Building:
Dwelling No.of Bedrooms Lot Size ' ! sq.tt.I Garbaggbr rider( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures'
Design Flow(min.required) 2.2 gpd Design flow provided i 1,5 ( gpd
Plan Date -I 11-7 Number of sheets )0 Revision Date
Title +
Size of Septic Tank � � Type of S.A-k
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) N10 S 0OQr4j `f"
2 fXhAS a? ' ' V 33 51 IrO ,S !
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 He th.
d Date 7
Application Approved by � Date �
Application Disapproved Date
for the following reas s
Permit No. 7-at h ' ZyZ Date Issued W a(&/S
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(I� Upgraded( )
Abandoned( )by ►3 t(3 _y (_D\J to j ion_
at In t 6 QQ0Z Q\J has been constructed in accordance
with the pro 'sions of Title 5 and the for Disposal System Construction Permit Nor��S " Z�Z dated
Installer ' o�� "(� I Designer Q1
#bedrooms 7 Approved de ' flow �G o gpd
The issuance oft is permit shall not be construed as a guarantee that the system 'll t on as des gned.
Date U 1 Inspector , lu
r
..�, , No � ' - - `-- - - - -_lZ
-_ -- - -- - - - - - _ Fee -- -
lJ'� 16-1
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Misposai 6pstem Construction permit
Permission is hereby granted to Construct( ) Repair(� ) Upgrade( ) Abandon( )
System located at 10
/ 1
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:Construct on must be completed within three years of the date of this permit.
Date ' 20�� Approved by
Town of Barnstable
oFZHE row�� Regulatory' Services
Richard V. Scali, Interim Director`
+ sASN51ABEZ, »
ss• Public Health Division
1639. �g
pTEo '° Thomas McKean, Director,
200 Main Street,Hyannis, NlA 02601
Office: 508 862-4644 Fax: 508-790-6304
Installer & Designer Certification.Form
Date: `,6 1� Z�`7 Sewage Permit# Assessor's Map\Parcel
Designer: Installer: '3-66
Address: ! - Address:
3 On as is
1 v ' ' "sued a permit to install a
(date) (installer) ,
septic system at ,' based on a design drawn by
(address) -
tr9, dated
(designer)
ertify 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 a
distribution box and/or septic tank. Strip out (iferequired) 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 thecSAS 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' on
1i nce with the terms
of the IAA approval letters (if applicable) S OF,�,
DAVID
r� SO MAi`l
(Installers Sib -
-
A\ "ten E4�
r.
(Design Signature) (Affix Desid io& p Here)"
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE,`VILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\DesignerCertitication Form Rev 8-14-13.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
10 Otis Road
u'i f i
Property Address t
Raymond Amaral
Owner Owner's Name/
information is H annis ✓ MA 02601 03-12-2021
required for every y _
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 51 1
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return
key. Company Name
52 Rivers End Road
�I Company Address
Teaticket Ma. _ 02536
Cityfrown State Zip Code
508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that:,I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have persona I ly'inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection;and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. Conditionally Passes
3. E Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
spect is Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
i _.
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
�^ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I
.......... , . 0 10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is Hyannis MA 02601 03-12-2021
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This 2 bedroom home has an H-10 1500 gallon septic tank with a D-Box feeding 2 leaching trenches.
At the time of the inspection no visible failure criteria was found.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by ,
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v—
10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis MA 02601 03-12-2021
page. City/Town State Zip Code Date of Inspection
C. Inspection'Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) .Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis MA 02601. 03-12-2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank'and SAS and the SAS is less than 100 feet but 50 feet or
more-from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�n
10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is Hyannis MA 02601 03-12-2021
required for every y _
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool'is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
i Title 5 Official Inspection form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis MA 02601 03-12-2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
® Have large volumes of,water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
i
c Commonwealth of Massachusetts
+m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�n
10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis MA 02601 03-12-2021
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): G plus
PD
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): town water
Detail:
For the past two years this location has used 301,444 gallons per water dept.
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts.
In Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�n
10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis MA 02601 03-12-2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No.
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
t
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
1- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis MA 02601 03-12-2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
Y
❑ 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 b system operator under contract
Y Y Y P
❑ Tight tank. Attach a copy of the DER approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
8-11-2015
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan): .
Depth below grade: 32"feet
Material of construction:
❑ cast iron Z 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Water was flushed and came freely.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis MA 02601 03-12-2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)`
6. Septic Tank(locate on site plan):
-
Depth below grade: 24"feet
Material of construction:
E 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:
H-10 1500 gallon
Sludge depth: 3„
Distance from top of sludge to bottom of outlet tee or baffle
33"
1
Scum thickness
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? sludge judge
Comments (on pumping recommendations, inlet and outleftee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the tee's were in place.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c� Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis MA 02601 03-12-2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official tInspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis MA 02601 03-12-2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0il
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids carryover.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
+n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis MA 02601 03-12-2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: , ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*if pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries - number:
z leaching trenches number, length: (2)2' x Tx 33'
❑ leaching fields' number, dimensions:
❑ overflow cesspool number:
innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis MA 02601 03-12-2021
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of the inspection no visible failure criteria was found.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration —
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction —
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
R'
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`. 10 Otis Road
Properly Address
Raymond Amaral ;
Owner Owner's Name
information is required for every Hyannis MA 02601 03-12-2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Otis Road
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis MA 02601 03-12-2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)`
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below: .
® hand-sketch in the area below
❑ drawing attached separately
At
i�•23' �to ��s T .
p3-30 A
� REA&
ag•$o3 �c Q
AW IV
161s A
3
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Otis Road
v
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis annis MA 02601 03-12-2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 10 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 at a lower elevation and shot it with a transit to show 4 plus feet of seperation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Otis Road
V
Property Address
Raymond Amaral
Owner Owner's Name
information is required for every Hyannis MA 02601 03-12-2021
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B:Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on . 16 or attached
9 P Y p9
For 15: Explanation of estimated depth to high groundwater included
. r
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
f
Town of Barnstable P#
-�-7z
�IVE
y' Department of Regulatory Services
,ntsxsuste Public Health Division Date
s6so. �s� 200 Main Street,Hyannis MA 02601
MA'I� 1'M1a
Time Fee Pd Date Scheduled f i ,4 0'i1 . ""
�t C-
t.
Soil Suitability A sessm t for Sewqze Di posal
0
Performed By: Witnessed By:
LOCATION&GENERAL INFORMATION
Location Address ,A� t Owner's Name
Assessor's Map/Parcel: G.�� Address Engineer's Name r��'l/�•9
NEW CONSTRUCTION REPAIR `�Telephone# 15 I
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line It Other - ft ,
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
,7L---
Parent material,(geologic) Depth to Bedrock
Depth to Groundwater:Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater "
DETERMINATION FOR SEASONAL HIGH WATER TABLE
-
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date; Index Well level Adj.factor Adj.Groundwater Level
PERCOLATION TEST Date Time
Observation
Hole# Time at 9"
Depth of Perc �jr Time at 6"
Start Pre-soak Time @ , Time(9"-6")
End Pre-soak /�- i�� / ,
Rate MinAnch / •-1` !I `' -
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel
r k
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil - Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Graven
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling, (Structure,Stones,Boulders.
Consistency,%Graven
DEEP OBSERVATION HO_ LE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
Flood Insurance Rate Mao:
Above 500 year flood boundary No Yes
Within 500 year boundary No Yes.
Within 100 year flood boundary No'V Yes
b
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pe ous terial exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the dep of naturally occurring pe i erial?
Certification (k
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Envtr en 1 Pro ti n d that the above analysis was pe ormed by me consistent with
the requir g,expe i e a ex eri nc described in 310 CMR 15.017
Signature Date
Q:\SEPTIC\PERCFORM.DOC
c
ASSESSORS MAP:
TEST HOLE LOGS 4�_
PARCEL: I Z
-_- 1) The installation shall comt�iy Mth Title V and Town o1'*� oard of.
FLOOD ZONE: LO ��
SOIL EVALUATOR : AOI
WITNESS : ��� �1�'t�..Ll 1 fealth Regulations.
q 2) -lie installer shall verify the location of utilities, sewer inverts and septic
REFERENCE: l
DATE: Vl. �26 �.,� components prior to installation and setting base elevations.
PERCOLATION RATE; .�- Z V1�lln�, 1 � 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first
\j// 14V• \,V/ a . 5-lb two feet out of the d-box to the ie�,ciiing shall be level.
4) This plan is not to be utilized for property line determination nor any other
TH I TH-2 purpose other than the proposed system installation.
> i I 5) All septic components must meet Title V specifications.
6) Parking shall not be constructed over H10 septic components.
7) The property is bounded by property corners and property lines.
'R- ;✓" ✓' ` �g ,7`' 8) The property owner shall review design considerations to approve of total
LOCATION MAP design flow and number of bedrooms to be considered for design. Receipt
• of payment for the plan and installation based on the plan shall be deemed
approval of the design flow by the owner.
9) The existing leaching or cesspools shall be pumped and filled with material
�-� c / per Title V abandonment procedures. Those within the proposed SAS shall
b �I be removed along with contaminated soil and replaced with clean sand per
IOY-
7� Title V specs.
U 4�, 10)System components to be 10 feet from water line. Sewer lines crossing the
water line shall be sleeved with 4 inch SC1140 PVC with ends grouted if
applicable. The proposed SAS is being installed below the water service
line. The line is to be sleeved as aforementioned and maintained in place.
_ SEPTIC SYSTEM DESIGN 11) 1f a garbage grinder exists it is to be removed and is the responsibility of the
f owner to ensure such.
FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such
exists.
\ \ BEDROOMS AT �� GAL/DAY/BEDROOM - GAL/DAY 13)The installer shall verify the location, quantityand elevation of the sewer
lines exitinv the dwelling prior to the installation.
SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting
---- Title V requirements.
GAL/DAY x 2 DAYS - GAL
USE .�GALLON SEPTIC TANK
�) ( o _- Chat►-l�'�.
SOIL ABSORPTION SYSTEM
Ir J �7 �
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pill 11W �� BO`t TOM AREA: �� k 0�7 H MASON
14o.1066 0 <�
AP
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_LP A1VIA
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SEPTIC TANK
or A-
SITE AND SEWAGE PLAN
LOCATION : 10
PREPARED FOR : � � CoS- 1
2
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SCALE:
DAV I D B . MASON RS DATE: l
s
DBC ENVIRONMENIfAL DESIGNS
W DATE HEALTH AGENT EAST SANDWICH . MA
W ( 508 ) 833- 2177
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