HomeMy WebLinkAbout0039 OTIS ROAD - Health 39 Olis Road
Hyannis F/R
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COMMONWEALTH OF MASSAC14USETTS
Board of Health, I$�O.�p�t MA.APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ' Upgrade( ) Abandon( ) -XComplete System ❑Individual Components
Location !S rl S Owner's Name
Map/Parcel# M04P 31, —V?3Q O(Qe) Address
Lot# a Telephone#
Installer's Name ��� Sc ;Qe Designer's Name S� Qv &UL
C Sy
Address fit'�+ � Address
Telephone# y - �� Telephone# -0�.
Type of Building %6gr �+O ^- /Lot Size tro sq.ft.
Dwelling-No.of Bedrooms �C� t`iCl �f1t' ���CG2 1�g\C,(1 ls) Garbage grinder
Other-Type of Building dR1Q No.of persons Q Showers (Cafeteria (y(
Other FixturesC`
Design Flow(min.required) r?, gpd Calculated design flow Design flow provided 3 •g8gpd
Plan: Date j O 3 Number of sheets I Q Revision_Date
_
Title �cm0�teA �12�4�C• �}-t Sa2h+ U Dom+ tt
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Gw- Am. P.TI-CGS a 52\c. .
DESIGNING ENGINEER MUST SUPERVISE
The undersigned agrees to install the above described Individual Sewage Disposal Syst iTA"TAQKM&h JhhY&TtftI`&5 and
further agrees to not t lace t m in operation until a Certificate of ComplianWK&SY&TIAhRIP4 WSM&EgfheST210T
Signed Date C CORDANCE TO PLAN.
�, o � S-
Iris-P ections
i.^'w`1.r`•14^">"-j.rw:.,.f�y�..v...�+..-,i +w'Mv``�iJ � -�.,.�r-^...'4H"y�ti'r.�'��k'�'#'�.�t,�?/�''"'��'f%i �^'�ls'�'"�4 •/'�'rR^+3__ .�lr:",-,r",^-.--.-...-�^'+s+'""""K'7'ry''["�
1Vo. u3 r 2to [ e FEE
COMMONWLA 714 Of MASSACHUS ETTS
Board of Health, AMA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIONARM-IT.
Application for a Permit to Construct( ) Repair( ' Upgrade( ) Abandon( ) -/T\Complete System ❑Individual Components
Location 39 n44
061 vA SAP O6t-, Owner's Name
v a...
Map/Parcel# M A p 311 , otv(D Address
Lot# - 2 Telephone#
Installer's Name � � ' Designer's Name �� � \ Sirs.
Address '"C^C ' TCiY,( CJv 1 c Address" x, �� . i no MA
Telephone# j . �t�g-5 1� Telephone# , C- Qa S3�
Type of Buildings Cie ��G� Lot Size e tabCa sq.ft.
Dwelling-No.of Bedrooms Cie,i�'\6 n C NVC'e 1.�y \�',(� J Garbage grinder
92 .Other-Type of Build ng u� brw No.of persons CD , Showers (Cafeteria (�)✓
r Other Fixtures �. Lao G 1VUQA t"°1 LC c
Design Flow(min.requredtt) gpd Calculated design flow Design flow provided 3 / < gpd -.
Plan: Date �> t Q�? Number of sheets Revision Date
t
'Title'
De'scri lion of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator C CMQ`l Date of Evaluation
i
DESCRIPTION OF REPAIRS OR ALTERATIONS Rpt^ CUlCt s'"7�C�c"1 >ti
w >. The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further'agree�s to not to
place the-system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed i /tn�KenQJ Date 10-1
'Q •:
r
No. Z Cp3- 2((6 FEE
COMMONWE ][114 Of MASSA HUS ETTS
, Board of Health ► Mft
t i
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) '^Complete System
The undersigned hereby cecti (that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded (•-)''Abandoned ( )
by: r.,d t e;i 5 S F' i 6 C—
at �r, C,7�i -S irlt'.,�
i
has been installed in accordance with the p ovi ions of 310 CMR 15.00 (Title's) and the approved design plans/as-built plans relating to
application No.Zoo 3- Z(Db , dated (7-10 3 Approved D- ig. F ow (g d)
Installer
The issuanceof this permit shall not be construed as
guaarantee that the Dater
Designer:
rr .. p guarantee system will function as designed......._ Y - ----- - -
No.
FEE S�
COMMONWEALTH Of MASSACHUSETTS
Board of Health, &4- r'1r 6-1 ,MA.
r DISPOSAL SYSTEM CONSTRUCTION PERMIT
g
Permission is hereby granted to; Construct( ) Repair( )I Upgrade( ) Abandon( ) an indi-6dual sewage disposal system
at Ci d-7 ' 5 f: z I. as described in the application for
Disposal System Construction Permit No.ZW3"2 -Z dated / /2 ®�
Provided: Construction shall be cbmr)ll`ete �ithi three years of the date of this p x i . 1 .o 1 conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date 4 0'"�- 3 ,Board of Health
v
TOWN OF BARNSTABLE
LOCATION SEWAGE # 3
0 —ZIOD
VI LLAGE H y � S ASSESSOR'S MAP &LOT 311 O® 6
INSTALLER'S NAME&PHONE NO.r RAL e C T S —
SEPTIC TANK CAPAC!nY T o-,'/
LEACHING FACILITY: (type) S�r2 Sul�r.x�� S (size) 10 X 34
NO.OF BEDROOMS a-
BUILDER OR OWNER I it S'o v�
PERMIT DATE: �
3 COMPLIANCE DATE: IZJD3
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
Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
4q - 1
Sep - 20-01 13 : 52 BARNSTABLE. HEALTH DEPT 5087906304 N . UL
-XOTICE: This Form Is To Be Used For dae Repair Of Failed
Septic Systems Only.
PEUCOLATI.ON 'PEST AND SOIL EVALUATION EXEMPTION
FORM
1' hereby certify chat the engineered pian signed by me
uatec 03 concerning the property located at
364i5 CPrQ 4AAA Wr)%S _ meets all of the
icl'o 4•,ng c-:7terla
• This failed system is connected to a residential dwelling only. There are no
.ornmztrzia.I or business uses associated with the dwelling,
• -F�e soil is ciassttied as CLASS l and the percolation rate is less than or equal to
.1.nuIts per inch. The applicant may use historical data to conclude this f3c' or may
:Dnduct ?re'im.tr,ary tests at the site without a health agent present.
• ;here :s no increase in flow and/or change in use proposed
• here are no variances requested or needed..
• The bottom of the proposed leaching facility will not be located less than fourteen
aonve the maximum adjusted groundwate("table elevation. (Adiust the
;rnunc:.vater table using the Fnmptor method when applicable)
Please complete the following:
Groun(1 Surfzce Elevation (using GIS information) _ 44'0�
A ry
g; t3.W E;cva(:or, -�_ I- ad;ustment for in,,h G.W. 01'�_ _
)'FT--FREINCF BETWEEN and B
_
S:(3ATE: c� ca
'>rE D D
NOTICE
3asec j-0n, tree ado4e information, a repair pernnit will be issued for aedroerns
bedrooms ate authorized in t`se future wt•.hout en,tncerec
:ept : sy tee plans.
-:nn:c:ou POCCAm9
f
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Loca 'on: C�S�e�• AAVqn+nz's Lot No. a,�A-x
NJ
Owner:,�L %yVt—�c�iM��R1 Address: '7)QMg
Contractor: ��nv�N �cCi�Address: _ 025
Notes:
STEP 1 Measure depth to water table
tonearest 1/10 ft. .............................................................................. .Date —'%� I �mon /day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OAppropriate index well.................................................... 450
OWater-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources.Conditions"
determine current depth to ®3
water level for index well ......................:
" month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B) I L
determine water-level adjustment • '"i
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water,
level at site (STEP 1)
Ir
Figure 13.—Reproducible computation form.
15
09/14/2013 20:56 FAX 001/001
CARMEN E. SHAY k (508)-548-0796
ENVIRONMENTAL SERVICES, INC. P.O. Sox 627,East Falmouth,MA 02536
June 13, 2003
RE: Certification of Title V Septic System Installatidn:
Residential Property—39 Otis Road, Hyannis,MA
Dear Sir or Madam:
On June 11, 2003, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at
39 Otis Road, Hyannis, MA, based on a design drawn by Shay Environmental Services, dated, June 9,
2003.
XX I Certify That The Septic System Referenced Was Installed Substantially According to the Plan
I Certify That the Referenced Above Septic System Was Installed With Changes but in
Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow.
k
The Septic System Was Not Installed Per State and'Local Regulations and Corrective Action is
Required.
If you have any questions, please do not hesitate to call the..undersigned at (508)-548-0796.
Sincerely
CARMEN E. SHAY
ENVIRONMENTAL SERVICES,INC.
N OF Mqs
CARMEN
E_
Y N
Carmen E. Shay, R.S., C.S. o. 1181
President Fcr s Y E��o
SgNITASN s.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
FAILED INSPECTION
TITLE 5 ,
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 39 Otis Road
Hyannis, MA 02601 RECEIVED
Owner's Name: Neale Tomkinson {
Owner's Address: MAY 12 2003
Date of Inspection: April 25, 2003 TOWN OF BARNSTABLE
HEALTH CREPT.
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map: 311
09"y4le,MA 02655-0049 Parcel.060
Telephone Number: (508) 862-9400 Lot:232
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
✓ a'Is
Inspector's Signature: Date: May 1, 2003
The system inspector shall sub 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
I
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 39 Otis Road
Hyannis, MA
Owner: Neale Tomkinson
Date of Inspection: April 25, 2003
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:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken laced
pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 39 Otis Road
Hyannis, MA
Owner: Neale Tomkinson
Date of Inspection: April 25, 2003
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 m accordance with 310 CMR 15.303(l)(b)that the
system is not functioning in a manner_which will protect public health,safety and the environment:
' I
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
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 aseptic tank and soil absorption.system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank.and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
4
3
Page 4 of 11
' OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 39 Otis Road
Hyannis, MA
Owner: Neale Tomkinson
Date of Inspection: April 25, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either`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 '/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 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
Yes (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or`no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone H 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 39 Otis Road
Hyannis, MA
Owner: Neale Tomkinson
Date of Inspection: April 25, 2003
Check if the following have been done: You mast 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:
Yes No
✓ 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(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 39 Otis Road
Hyannis, AM
Owner: Neale Tomkinson
Date of Inspection: -April 25, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): 2001-68,250 gals.;2002-16,500 Qals.
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMIVIERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): _____.gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:---- _Never pumped-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
✓ Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
E Page 7 of 11
OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 39 Otis Road
Hyannis, MA
Owner: Neale Tomkinson
Date of Inspection: April 25, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron 40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank)
Depth below grade: 15"
Material of construction: _concrete_metal _fiberglass _polyethylene
✓ other(explain) Cesspool block
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 6'Wx 4'Tx 6'bottom to grade
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle: --
Scum thickness: 12"
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: Measzy*g stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert;evidence of leakage,etc.):
Liquid in the cesspool was up to the outlet pipe, Scumisolids were thick. The solids were leaving the cesspool and getting into
the leach pit. The cover was 15"below grade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
• Page 8 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 39 Otis Road
Hl annis, MA
Owner: Neale Tomkinson
Date of Inspection: April 25, 2003
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: =concrete metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,edition of pumps and appurtenances,etc.):.
8
x
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 39 Otis Road
Hyannis, M4
Owner: Neale Tomkinson
Date of Inspection: April 25, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type �I
✓ leaching pits,number: 6'x 6'(1000 f_al.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovativelalternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
The pit had Yofwater on the bottom. The scrim line was up to the inlet pipe. Solids were present. The cover was Y belowQrade.
The pit was in failure.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid.to inlet invert:
Depth of solids layer
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes,or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
f
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 39 Otis Road
Hyannis, MA
Owner: Neale Tomkinson
Date of Inspection: April 25, 2003
Map:311
Parcel:060
SKETCH OF SEWAGE DISPOSAL SYSTEM Lot:232
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.
A Q
Aa-
13SL- cio
10
Page I 1 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 39 Otis Road
Hyannis, MA
Owner: Neale Tomkinson
Date of Inspection: April 25, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20 +/- feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If,checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You mast describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
20'+/-to ground water at this site.
This report has been prepared and the system inspected and failed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11 ,
11/20/2001 14:40 5088217684 HAMMOND DELEADING PAGE 01
MAR. 9.ZWI �'1�+'i'i u�� w�� ,,L,r••.�
DepartMvnt of Mlic iffealtht Department of Lzbor by WorWree Development
t N,0TMCA'%'I X OF DDLE iDI NG'WORD
411 SeettM of tbbi form must b4 completed in order to comply with
thr notification roquircments ofn4GJ..C.111§197,
454 CMR:2 00 aad 105 CM 460,000.9$M09t recently amended
b - Hammond Deleading l,flcense DC1068 gxp,Date 6-09-a,�
Cout-Acton per#brmfag_,rol I`
ilLemd PamIaspectot a-Date of Ynspectlon 1 I a ^,i.icease# a� xl�
' I
i
AD7DRDM OF MJEC"1':
5inet Addrm� 'n Zd Apt.dumber
zip (g
4 L L g' Oa. a 1
�a
Pa opwy ow,lero_'y�'l1 &A
Talepkone N►monber
beleadSng Method: 9Jei133zy Scxa is Heat Gun Ligu t
Caesdics elsloeemenb
cowring Outer .
If`°other,seleded;pleeae 4Mplaiz
Sin le✓fain +_ _ Other
Choelc one, Dwellaad•is multi-fixmily �
1 �01 complet aDate„
Start bane• / ._._
%tio w4ll work be dome:
AaM Pl''I (S#recify hates us site) �Veekenas?
Nark Harrin ton Lffiensa ,—DS3229 Ecp,Date 3�1.9-0?_
• Project 8yapcsVi9or Naaag � .
555X774 Reliance,
Wortces s CpmpeDsat4oa Policy Number Canner
John Hammond Tel 5�as 821--7684
It case o£emorgeucy Cottact .
(Contradws Representative). Cell# (5 0 8) 2 4 3 16 6 8
DEt F sbING
The undersigned hereby stAtesr under the prime area RemsWes ofpjury,flat helsbLe I:as read and undoxstood the Commonwealth Of iv[assnehuaetts DelgadhIS RAgRladana, Q CNfR 22.00,ago d Lead Po4so g Prevention xna Coabrot Itcgttlationy,205 C1rQt
4G0.000,and that fire grmah .tiea csangined in t3�fe hotel On EA
rrect to ®9 hicAter kuawlede 4td ltstieE
Date
eompanpName Hammond Deleading
Addxm 19 OrctlhEd Street- Berkley MA 02779
Tatphon®Numbcr (508) 821-7684 Cell# (508) 243-1668
I
Commonwealth of Massachusetts
. I U Title 5 Official Inspection Form
,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments j
Property Address
Owner Owners Name
informa
tion is
required for every A 1i h 1 14 od 6 0
page. Citylrown State Zip Code Date of I pectio
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 Inspector. (/t
key to move your 1.
cursor-do not G✓
use the return
key. Name of Inspector I
Company Name
�o �Ox Id-og ,
Company Address s�� �•,,
Crty/Town -
/9 01) 6 1�C2
r State' Zip Code
0
Telephone Nu er License Number
B. Certification -
i
i
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 C 15.000). The system-
Passes ❑ Conditionally Passes
❑ Fails
1
❑ Needs Further Evaluation by the Local Approving Authority
Inspector 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.bu,y.er;;ift applicable, and the approving authority.
RR"This repot#Tonly describes conditions at the time of inspection and under the conditions of use i
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
tsirls•,vio fl `
F ' I t fit'€ U rn"esorr�ii
,� nspedan Forrn:SubsurfaceSevoge p system•Page 1 oft 7
Commonwealth of Massachusetts
Title 5 Official Insipection Fora
Subsurface Sewage Disposal'Syst6m Form - Not for Voluntary Assessments
Property Address
Owner Owners Name
information is n
required for every L ✓�
page. Cityrrown State Zip Code Date of lXspectfon
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E /always complete all of Section D a
A) System sses:
I have not found any information which indicates that any'of the failure criteria described
in 310 CMR 15.303 or in 310 CUR 15.304 exist. Any failure criteria not evaluated are ;
indicated below.
L
Comments:
i
i
h
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be I
replaced or repaired. The system, upon completion of the replacement or repair, as approved by I
the Board of Health, will pass. I
Check the box for"yes', "no" or"not determined" (Y, N, ND) for the following statements. If"not ,
determined, please explain. i
i
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 ff a Certificate of
Compliance indicating that the tank is less than 20 years old is available. 1
❑ Y ❑ N ❑ ND(Explain below):
t5ins•11110
Title 5 Official Inspection Form:subsurface seviage Disposal System•Page 2 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner
Owner's Name
information is
required for every kj n �_
page. CitylTown state Zip Code Date of IKspecti6n
B. Certification (cont.)
B) System Conditionally Passes (cont.):
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):
I
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): j
❑ obstruction is removed ❑ Y ❑ N '
❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): fi
I
— I
❑ 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): C
I
❑ obstruction is removed ❑ Y ❑ N
t
❑ ND (Explain below): C
F
--- rI
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which requirie 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
lSlns•1 vio
Title 5 Official Inspection Form:Subsurface Sewage Disp System.pge 3.(17
i
f
6
Commonwealth of Massachusetts•
Title 5 Official k'SPection Form
Subsurface Sewage Disposal System-Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is /f,� Ci t�1✓��S fi/� (/O�G �� l�
required for every
page. City/Town State Zip Code Date of Indpectio6
B. Certification (cont.)
4
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 i
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 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. {
I Other: i
I
E
it
m }
D) System Failure Criteria Applicable to All Systems:
I
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 %day!flow i
ts�„s•uno
TMe 5 Official Inspection Form:Subsurface Sevage Disposal System•Page 4 of 17
- i
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form • Not for VoluntaryAssessments
S
Property Address
olve, J _
Owner Owner's Name
information is / �L �� 6 a
required for every ✓�I �
page. City/Town State Zip Code Date of In pedio t
B. Certification (cont.) i
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
❑ 2-` Any portion of cesspool or privy is within 100 feet of a surface water supply or I
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 welli.
❑ Lad' 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. [Thl§
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence 1
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-
/ 1 pd.
❑ I��,/ Thehe system fails. I have determined that one or more of the above failure i
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 considlered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 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 Protection11
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,j
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 C M R 15.304. The system owner should contact the appropriate
regional office of the Department.
t5irts•11110
rdle 5 OMCW Inspection Forth:Subsurface_%_go Disposal System•Page s o/17
I i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79
Property Address _
Owner O ---wner's Name j
information is n ,l� �] ) 1�
required for every C1 �'/�s /�/J y v 6�� / 13'1 j
page. City/Town State Zip Code Date of IvIspecti6n i
C. Checklist
Check if the following have beeni done'You must indicate"yes" or"no" as to each of the following:
Yes No
P
❑ Pumping information was provided by the owner, occupant, or Board of Health
{
i
❑ ere any of the system components pumped out in the previous two weeks?
❑ Has the system received normal flows in the previous two week period?
ElHave 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 t
available note as N/A)
Was the facility or dwelling inspected for signs of i sewage back u ?
9 p
Ti Was the site inspected for signs of break out?
^/,.❑ Were all system components, excluding the SAS, located on site?
L�' ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank I
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 subsurfacese
wage 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): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): y
l5ins•11/10 .
rrtle 5 Official Irmmchon Forms subsurface Sewage Disposal System•Page 6 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
o;
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
- Property Address
Owner Owners Name ---- — ---- / -- I
information is el P14 c f
required for every Al
page. City/Town State Zip Code Date of Inspectio
D. System Information.
Description: C � � I
S �L-✓t 1111 , 01-Y' IV j
I
O
Number of current residents:
Does residence have a garbage gnnder? ❑ Yes
/No
E ll
Is laundry on a separate sewage system?,[if yes separate inspection required) ❑ Yes Noi
Laundry system inspected? ❑ Yes of
Seasonal use? 1
❑ Yes of
Water meter readings, if available(last 2 years usage (gpd)): I.
Detail
I
I
i
l
Sump pump?
❑ Yes o
Last date of occupancy:
Date
Commercial/industrial Flow Conditions:
Type of Establishment: -
Design flow (based on 310 CMR15.203): i
Gallons per day(gpd)
i
Basis of,design flow (seats/persdns/sq.ft., etc.): --
l
Grease trap present?
❑ Yes ❑ No l
Industrial waste holding tank present? ' ❑ Yes ❑ No.
I
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No i
I
Water meter readings, if available: !
I
r5ins•,v,o
rrtle 5 official Inspection Form:Subsurface Sewage Disposal System•page 7 or 17
i
P .
Commonwealth of Massachusetts i
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
n JJ
Property Address 0 Ale l /
Owner Owner's Name �p
information ! q vl N/� 0d 6 0/ 3� I
page.
required for every Coffown 011 State Zip Code Date of I pest' n
D. System Information (cont.)
Last date of occupancy/use: Date
1
Other(describe below):
i
}
i
1
I
General information
• i' i
Pumping Records:
Source of information: cr I
Was system pumped as part of the inspection? ❑ Yes ❑ No
t
9
If yes, volume pumped: gallons
How was quantity pumped determined? II.
Reason for pumping: --- —
I
f
Type of Sy
I
Septic tank. distribution box, soil absorption system I
❑ Single cesspool E
I
❑ Overflow cesspool
i
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) `
I
❑ Innovative/Alternative technology. Attach a copy of the current operation and
t
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
I
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Trite 5 Official In
spection Form:Subsurface Sewage Disposal System•Pege 8 of 17
i
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0/a
Property Address
f i
Owner Owner's Name
information isq 0 N 1-5 /'/ 0,)(201 3 Z/Z
required for every
page. City/Town. State Zip Code Date of In ion
D. System Information (cont.)
I
Approximate age of all components, date installed (if known) and sourc of inf rmation: i
i
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan): //`6
Depth below grade. feet
Material construction: k
i
cast iron 40 PVC ❑ other(explain): //
/0
• Distance from private water supply well or suction line: feet {
Comments (on condition of joints, venting, evidence of leakage, etc.):
I
i
Septic Tank(locate on site plan):
Depth below grade: feet
Mats f e 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:
r5ins-11/10 Title S Chffidsl Inspection Forth:Subsurface e Sewsg Disposal System-Page 9 of 17
I
Commonwealth of Massachusetts.
771
Title 5 Official lnspectiom Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address i
Owner Owner's Name
information is i
required for every 475 �/ Q�6Q� A,/
page. CitylTown State Zip Code Date of Inspection
D. System Information (cunt:) ,
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
SS=--Scum thickness Z_e i
Distance from top of scum to top'of outlet tee or baffle
Distance from bottom of scum tobottom of outlet tee or baffle '
^l I�
How were dimensions determined? ° / W67 `_eV/I( .
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
V17 Y7 er, 0 o"i—e(-,U
/ i
TI✓1'I.e
. f
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: i
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
f Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
{ �I
Date of last pumping: i
Date
t5ins•11110 Title 5 Official Inspection Form:Subsurface Se%ege Disposal System-page 10 of 17 1{t
Commonwealth of Massachusetts
Title 5 Official lIn'spection Form
Subsurface Sewage Disposal System form --Not for Voluntary Assessments
r
Property Address
Owner
Owner's Name
information is 1
v> 0 /required for every /�
page, CityRown State ` Zip Code Date ofinspktion
D. System Information.(cbnt.)
Comments (on pumping recommendations, inlet'and outlet tee or baffle condition, structural integrity,11
liquid levels as related to outlet invert, evidence of leakage, etc.):
_ � f
I
Tight or Holding Tank (tank must be pumped of time of inspection) (locate on site plan):
Depth below grade:
Material of construction: p
❑ concrete ❑ metal :❑ fiberglass
❑ polyethylene ❑ other(explain):I
Dimensions:
4
� t
Capacity: —
gallons
Design.Flow gallons per dayJ
Alarm present: ❑ Yes ❑ No
Alarm level' Alarm in working outer. ❑ Yes ❑ No
Date of last pumping Date
Comments (condition of alarm and float switches, etc.):
i
*Attach copy of current pumping:contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 official Inspection Form.Subsurface Sewage Disposal System•papa 11 of 17
I
4
. I
I
I
Commonwealth of Massachusetts
Tithe 5 Official In spection Form j
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owners Name
information is b, C,0ki11 �6 D/
required for every Ll
page. Cityrrowln State Zip Code Date of InipectioAj
D. System Information (cant.) '
Distribution Box (if present must be opened) (locate on site pian)- I
Depth of liquid level above outlet:invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, anyl
evidence of leakage into or out of box, etc.): I
i
SO/I C�r
M/p z �� f
I
Pump Chamber (locate on site plan): !
• i
Pumps in working order. ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No I
i
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
- I
I
Soil Absorption System (SAS):;(locate on site'plan, excavation not required): f
If SAS not located, explain why:
I
i
l
• k
i
rsins•t tno rdle 5 official Inspection Form:subsurface sewage Disposal system•page 12 of 17
F
b
I
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
-29 _
Property Address
Owner Owner's Name
information is o o 4 l j / 0.2601
required for every
page, City/Town State Zip Code Date of Inspection I
D. System ormatlon (r;ont.)
Type' S/
I
❑ leaching pits number:
• l
❑ leaching chambers. number:
❑ leaching galleries number:
❑ leaching trenches number, length: 1
I
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: ---
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
f
i
c1l ✓r..J D� lG� l(C
i
of t l.v�• I
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet inverjt
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
i
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
i
t5ins•,v,o
Idle 5 OffcW Inspection Form:Subsurface Sewage Disposal System•page 13 of 17
C
i
}
Commonwealth of Massachugetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i Property Address _
I
Owner owners Name
information 5 a�4/�r
required for every
page. Cityrrown State Zip Code Date of pecti n
D. System Information (cant.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
i
Privy(locate on site plan):
I
Materials of construction: —
t
j
r
Dimensions
Depth of solids —
i
Comments (note condition of soil! signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
j
I
i
i
i
i
I
i
15in5-11/10
refs s Offival Inspection Form:Subsurface sewage ofsposai Symem•Page 14 of 17 I
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
o s gc/
Property.Address
Owner Owner's Name
information is 0,Y1 �f �
required for every
page. Cityrrown State Zip Code Date of Inl6pecticIn
i
D. System Information (cunt.)
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 pu is water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
i
i
� VV �
i
t5ins•11/10
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 15 d 17
Commonwealth of MassachUsetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for-Voluntary Assessments
9 i2d
Property Address --
A;e
Owner Owners Name r) �� od 6c�/ % `
information is � f'
required for every
page City/Town State Zip Code D e of 1 spection
D. System Information (cont.) .
Site Exam:
❑ Check Slope
i
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high groundwater:
_ 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.-
0 Checked with local excavators, installers (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
(A Gh G14 / 0
1p 14-1 C�"'4V /OC �e
I �o L4('4 �w
Before filing this Inspection Report, please see Report Completeness Checklist on next page. j
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sevsge Disposal System•page 16 of 17
f
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is �1l/f/1 do�6d� / '
required for every
page City/Town state Zip Code Date of Inspection
E. Report,Completeness Checklist
Inspection Summary: A, B, C, D, or E checked
inspection Summary D (System Failure Criteria Applicable to All Systems) completed
S 'e formation - Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 ride 5 Official inspection Forme subsurface Sev+age Disposal system•Page 17 of 17
e
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE-OFFICE OF ENVIRONMENTAL ,F�rFAIRS
DEPARTMENT OF ENVIRONMENTAL PRO- ON.�f /PEZ?
ONE WINTER STREET, BOSTON MA 0210& (6171 2-55001
6
Phsr DO i
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI _ - - DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 39 Otis Road, Hyannis, MA . Name of Owner: Robert Almauist
Address of Owner: 25 Hover Avenue
Date of Inspection: October 10, 2000 - Quincy, MA 02169
Name of Inspector: (Please Print) James M.Ford.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(MO CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map:
Telephone Number: (508)862-9400 Parcel:
CERTIFICATION STATEMENT r17.
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 inspection. The inspection was performed based on,my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
-Passes
Conditionally Passes
` Needs Further Eval By the Local`ApprovingrAuthority
Fails
_ .
Inspector's Signature: Date:, October 11, 2000
The System Inspector shall sub a copy of this inspection report to the Approving Authority.(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.'
NOTES AND COMMENTS
revised 9,/2%9 8 :Alijel.I of'lr
Printed on Recycled Paper ' " F
ti
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 39 Otis Road, Hyannis, MA
Owner: Robert Almquist
Date of Inspection: October 10, 2000
N SUMMARY: Check A B C
INSPECTION , or D:
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
Indicate yes, no,or not determined(Y,N,or ND). Descr'_be basis of determination in all instances. If"not determined",explain why not.
_ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
'Health)
_ broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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 reeved
revised 9/2/98 Page 2of11
r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
,.PART A
...CERTIFICATION (continued)
Property Address: 39 Otis Road, Hyannis, MA ', ., .. ;.• ,
Owner: Robert Almquist
Date of Inspection: October 10, 2000
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
,� ,y 1� r, � a o•.r
, ,,. ., L#'.•.#fit=ts
Conditions exist which require further evaluation by the Board'of Health in order to determine if the system is failing to protect the
public health,safety and 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 THE PUBLIC HEALTH AND
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.
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 AND SAFETY AND
THE ENVIRONMENT:
The system hag a' tic tankand:soil abso tion's st y sep' rp y em(SAS)and.the-SAS,is Within 100,feet to a surface water supply or
'tilbut'ary�to--a:iiidace-water supply.!
_ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has aseptic tank and soil absorption system and,the SAS is;within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the,SAS,is.less.,than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliforn bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less .
than 5 ppm. Method used to.determine distance (approximation not valid).
r
3) OTHER
t
revised 9/2/98 - Page3of11
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 39 Otis Road, Hyannis, MA
Owner: Robert Almquist
Date of Inspection: October 10, 2000
D. SYSTEM FAILS:
You must indicate either"Yes" or"No" as to each of the following:
_ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an 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'/z day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAEl S:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 39 Otis Road, Hyannis,MA t•t .j�Y,,,�?,� y.. _..•,
Owner: Robert Almquist 1.:�. .. ;..
Date of Inspection: October 10, 2000 f, •;r .t t vi ; '
s ,:,P.'E Ctt�t:sir'".3 rx`3CT i'}t .: , "�, ,. `'3^=`'}.. !:L (i:,j�a•
Check if the.following have been done-. must:indicate either..."..Yes".ror",No".as to`each.of;the:followmg:.;
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of.Health.
*✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection. (*The house was unoccupied.) a
n/a As built plans have been obtained and examined. Note if they,are-not available,with'N/A. tF
✓ The facility or dwelling was inspected for signs of sewage back-up:
✓ The system does not receive non-sanitary or industrial waste flow.-
The site was inspected for signs of breakout.
✓ _ All system components,excluding the Soil Absorption System,have been located on the site.
,_.
✓ _ The septic tank manholes were uncovered,opened;and the interior of the septic tank was inspected for conditions of baffles
or tees,material of construction,dimensions,,depth of liquid,,depth of sludge,depth of scum.-The size,and location of the Soil Absorption System on the site has been determined based on:
do Lt
✓ Existing information. For example,Plan at.B.O.H.
✓. " ' _ Determined in the:field(ifiny of the failure criteria related to Part C is at•:issue;-approximation of distance is unacceptabfe)
[15.302(3)(b)]• r
✓ The facility owner'(and occupants, if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems. 4
,
revised 9/2/98 ,Page5of11
' y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 39 Otis Road, Hyannis, MA
Owner: Robert Almost
Date of Inspection: October 10, 2000 t
FLOW CONDITIONS
RESIDENTIAL:
Design flow: n/a g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 2
Total DESIGN flow n/a
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry(separate system)(yes or no):No laundry If yes,separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last two year's usage(gpd): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unlaimm
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: mA(Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Pumped 4 years ago-per owner
System pumped as part of inspection(yes or no): No
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
✓ Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: Unknown
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
L T
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 39 Otis Road, Hyannis, MA
Owner: Robert Almquist
Date of Inspection: October 10, 2000
5
BUILDING SEWER:
(Locate on site plan) 3 , :;: 1 i
Depth below grade:
Material of construction: cast iron _40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: None
(locate on site plan)
Depth below grade:
Material of construction: _concrete metal _Fiberglass _Polyethylene _other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions:
Sludge depth: _ • _ ..
Distance from top of sludge to bottom of outlet tee or baffle: _ t ;y 3 - • R �?
_ .-.Scum.thickness:.. .._.
Distance from top of scum to top of outlet tee or
Distance from bottom of scum to:bottom of outlet tee or baffle:
How dimensions were determined: "___w.._.. _.M _:.... .,. � .,.. ... _ __ 3 - IT,,)
Comments:
(recommendation for pumping,condition of inlet and,'outlet tees"or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
GREASE TRAP: None 2.
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal- Fiberglass _Polyethylene,_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:..
Date of last pumping: ;
Comments:* ,
(recommendation for pumping,.condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence..of leakage,.etc.)_ w
revised 9/2/98 Page 7ofu
b•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 39 Otis Road, Hyannis, MA
Owner: Robert Aln q ist `
Date of Inspection: October 10, 2000
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time,of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order: Yes_ No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: None
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: .
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP CHAMBER: None
(locate on site plan)
Pumps in worldng order: (Yes or No)
Alarms in working order: (Yes or No)
Comments:
(note condition of pump chamber,condition of pumps.and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'C
SYSTEM INFORMATION (continued)
h
Property Address: 39 Otis Road, Hyannis, MA �� , .,•,,•- <•- .�,
Owner: Robert Almquist
Date of Inspection: October 10, 2000 �
SOIL ABSORPTION SYSTEM(SAS) ✓i', ngtti` ;.
(locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive'methods)
If not located,explain:
Type:
leaching pits,number: I-6'x 6'
leaching chambers,number: .
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,`etc.)
The pit had I'of water on the bottom. The scum line was 4'6"up from the bottom. 'There were solids in the pit. The bottom to grade was
proximately 9'6" The cover was 3'below grade. Recommend installing risers to•bring cover within 6"of grade. Y
CESSPOOLS: ✓ , P
(locate on site plan)
Number and configuration: 1_w/overflow
Depth-top of liquid to inlet invert: --
Depth of solids layer: 3" u,w
Depth of scum layer: 0"
Dimensions of cesspool:6'W x 4'Tx 6' bottom to grade
Materials of construction: Block
Indication of groundwater: None
inflow(cesspool must be pumped as part of inspection).
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
The cesspool had 2'of water on the bottom Recommend installing new tee on the outlet pipe Solids are getting into the pit.
PRIVY: None
(locate on site plan)
Materials of construction: Dimensions:
—Depth of,solids-:
Comments: R
(note condition of soil, signs of hydraulic failure; level of ponding,condition of vegetation, etc.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 39 Otis Road, Hyannis, ?I1A
Owner: Robert Almquist
Date of Inspection: October 10, 2000 •• -
Map.
Parcel:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
3q�k
A �
Al - ay
�a- 140
C
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM
PART C
i SYSTEM INFORMATION (continued)
Property Address: 39 Otis Road, Hyannis, MA � i i •.n:, �{.,F.F� x`rJ = ;E - :4 r
Owner: Robert Almquist t s�tti•t;.c1r.'` n�,w
Date of Inspection: October 10, 2000 'lo we:i
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep.
SITE EXAM Slope
Surface water
Check Cellar
• e
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
✓ Determined from local conditions
Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
Check local excavators, installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Y
The bottom of the pit to grade was approximately 9'6". Using the USGS topographic map and the Cape Cod Commission
water contours map, the maps were showing approximately 20' +/-to groundwater at this site. Using the Cape Cod
Commission Technical Bulletin,the high groundwater adjustment for this site(AIW 230, Zone D, 8100)was 6.0'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
• written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11of11
OF WE
Town of Barnstable
9: HAM Board of Health
w .
ArEO►�o+°i P.O. Box 534,Hyannis MA 02601
Office: 508-8624644 Susan G.Rask,R.S.
FAX: 508-790-6304 Ralph A.Murphy,M.D.
Sumner Kaufman,M.S.P.H.
To: ALMQ UIST ROBERT H Date Monday,March 05,2001
%BERRIOS,MARIO JR
39 OTIS RD
HYANNIS MA 02601
RE:Underground Tank at 39 OTIS ROAD
Map/Parcel 311060
Tank NO: 01
Tag NO: 01050
The Town of Barnstable Public Health Division records indicate that your undergroud
or chemical storage tank is 10 years of age,and has not been tested as required under section 07:(5)of th
health regulation regarding fuel and chemical storage systems.
You are directed to have each tank and its piping tested within thirty(30)days of the receipt of this
notice. Results of the testing shall be tiled with the Board of Health and the Fire Department.
You are reminded that you shall have the tank and its piping tested during the loth,13th, 15th,17th,
and 19th year after installation,and annually thereafter.
Failure to comply with this order may result in a fine of up to$300.00.Each day's failure to comply with
an order shall constitute a separate violation.
You may request a hearing if a written petition requesting same is received by the Board of Health
within ten(10) days after this order is served.
Per Order of the Board of Health
Thomas A.McKean, RS, CHO
Health Agent
L
L_OuCATION <- �eS SEWAGE PERMIT NO.
VILLAGE
INS'TA LLER'S NAME & ADDRESS
O U R D E R OR OWNER `
Is, -,A n r4
b
DATE PERMIT. ISSUED
,w:a,OATE C0M'PLIANCE ISSUED - )/- 7 ��,
. }
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i .. ' �f�
i
J
���
y, �;�,
C
L. � � 1
3 q �•Ut�TOWN OF BARNSTABLE
1 LOCATION "S t`� SEWAGE #
VILLAGE HN AAell-S ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONEE NO. L.' a 3
SEPTIC TANK CAPACITY CZS'Pob
LEACHING FACILITY: (type) P) (x G (size) .
NO.OF BEDROOMS a"
BUILDER OR OWNER
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 Feet
within 300 feet of leac g facili�Y_).�._
Furnished by •�^sPcc. a^ J - Foy
(%l7
_ 1Fi
� i
� fi � �
�C. -C
� �
D
C
n�
L
Cn�
k
�� �__ -
' CJ
TOWN OF BARNSTABLE
LOCATION O�Ci S Rc�. SEWAGE #
VILLAGE �v C-rL✓LZ S ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. RS p¢-e
p SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) Y/ f? At/ 2 S (size) /D Y 3�
NO: OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: I2 �' COMPLIANCE DATE: c Z 03
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
� �
r
� 9
��p
f
�'
Y�
f
.s
O o Q l�
,.
R�
l� Q
� �.
.L
_ ..z -.!
.'..
TOWN OF BARNSTABLE
y ` 3� csrs R.c�.
LOCATION � � SEWAGE #
VILLAGE 14 TN AAA'I S ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO '
SEPTIC TANK CAPACITY D ov
LEACHING FACILITY: (type) t (size) �X
NO. OF BEDROOMS C
BUII,DER OR OWNER
R o ✓� U I S
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: dE,
Maximum Adjusted G oundwater Table to the Bottom of Leaching Facility -e 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
O
CL [�
__
;. 777
,. SECTION A A „ 1 w000 r
m n 0 from
T PIP 4*NOTE: ALL ARE T H ES 0 BE 4` P.V.C.
SCHEDULE 0 P amET apEs FRow ,
Ex
isting rn Foundation
1NE ,,
t rt ;
to tic tank P D °
9 _ �hou*e on R FILE VLEi�';OF DDITION :T .: Hat[>� t A O LEACHING .SYSTEM: orsTr�irTra,sox swAu me
ett Road-Ro
12 -
!t: l T ..
t tank covers.must M ' SE LEVEL fttR AT LEAST z FT. CAktGRETE R
TOP OF FOUNDATION -'ELEV, t (Assumed)
10 00 00_iAssu ed) . . f'�T t<• 3 0 8 - Woshad Peoston
rnthn 6 m. ;of fwwshsd grade � � ,
9 ,
Grade oa Septic Tank 91 a0 Grade'ovrrD ex D9 50 o0s oe SAS �4 :to 1 T� Yoshed Crus
hed Stone .,
: 3- OUTLET r
•.+
KNOCKOUTS S�
>, I
T
s 0.02 ourLET
it INLET
3;►tOlE M t0
pIST:BOX
3 Yoarrwrn Cover
H t NEW .S.O.Ot Top of 5A$ Elev. 96.75 r. :
0 or Great�` to tr
Ext_T. PIPS _ 1,500 GAL. v
p S. 0.01 foot •
>c 8 r7 p«
2t t . '.
FROt EXIST. FOtIr4DAT1Dt s s
w SEPTIC TANK n Ettsdrye to 4 - ,
n Depth
i; SCH. 4o Tee- t.7S .j•
�p
o, H t N is
N
0
or sir N Units Q r;f 2CROSS—SECTIONi
PL N A S CTiON> r - a �_
CONCRETE rlxL Fou►,arc)i
> M �' 3
2
6 in-of 4'-1 1/2"
} _ n � B
/ AXT R
.:SYSTEM PROFILE � �: _
E RDA
> a,- D
Compacted ,,,� � s 3 HOLE H 10 DISTRIBUTION BOX
y
q
c Effective Not to'Scob �-12.
p ec#I a Length_ u 9 NOT TO SCALE
( t
'0 4
E
c _ 4
_ UCJCUS ��f�F
c � 5 �'
u
> SDI ABSORPTION
, t 4_ t0 L BSOR IDN SYSTEM (SAS)
6 rno 3/ t t/2 c (,
ff' --
E ��. tr N
z t . va GENERAL NOTES compacted stone L
CULT
ag _` EC MODEL 125 (H 20 LOADING)/ SHDREY PR A EC STE
nr. Co t actor s responsible for Dr of notification
@Qttaro_r!_Isat _______. s e
i9
OR EQUIVA NT Not`to Scale
a { LE ) Sae and protection of oil underground
P utilities and ,pipes. '
2. The i -
N07E. OVERALLHEIGHT I ' a septic c tank and distribution OF INFILTRATOR IS 18 JEFFECTIVE HEIGHT IS 12 P ,, box shalt be set
lever ,on f - "6 0 3/4 1 J2 :.stone.
3.: Backfill should.be clean sand or gravel with no
son over
t es o e 3 ,n size.
4. This ,
i- s system Is .sub ect to_.Ins inspection during installation
1 p g
b Carmen E. Shay Environmental •
Y Y_ Services, Inc.
The n 5 e contractor shall install
v stp .this System ,n accordance
PERCOLATION TEST Y
with Title V f t o the Massachusetts,,state code, the approved �Iar
:.n :.:
PP F
and Local Regulations.
f
9
Date o Percolation Test. DUNE 6 2003
6. If, duri
ng tnstollotron the contractor encounters
� Test Performed B CARMEN E. SHAY, R.S ' C.S.E.
9 any
Y • . ,
soil conditionsr
Results Witnessed By. WAIVER per Bornstable'B.O.H.
o .site conditions that 'ore different
from
o those Shown 'on the sort to ' or in our design
Excavator, ROBERTS SEPTIC SERVICE installation
g 9
in ll
stp ptron must halt ,& immediatenotification
{ Percototlon Rote.. less Than 2 MPI
,be
made to Carmen ,
Ca en E. Shay Environmental .Services Inc.
Y .
7 N ve
hicle chicle or`he ma
chinery ochrnery shall drive over the
-
septic s stem 'unless:-noted as H r
Test H I,
Y 20 septic components.
s Hp le , ,
r -
8. Install T
II sto of Ttte gas baffles ` r I g es o equals on all outlet tee enas.
No. 1
AllDistribution` - " j ,
9 Lines shall be 4 diameter Schedule 40 'NS PVC pipes.
.
C P pe,.
DEPTH SOIL S ELEV. 10. All solid„piping, tees' dt fittings shall .be 4 diameter
`
-LOT 232Y g
Schedule 40 NSF PVC pipes with water tight P P ate ,t g t joints.
Sandy '
Y
11 Municipal\\ Water is Connected
o ected to ALL OF The Residence a�d Ab�ttm
Loom � 9
to
Properties Within 1 F
to YR }/z tp � � Pe 50 eel.
0"-6' Af 98.90 I _
..:.
THE PROPERTY LINE ARE APPROXIMATE
Loamy I .+ 1
S E ROXIMATE AND
a Y COMPILED FROM THE =SURVEY -PLAN L.C. ,t 1519 G S-iEET 2
Sand Qs.
AN 1 D SNOT INTENDED`TO BE A SURVEY`P T P
o YR s/6 I 111.52 ----------- --`
PLOT LAN
---- IT -
r SHOULD BE 'USED FOR NO'P RP_ B I U OSE-OTHER_THAN
6 38 . 96.25 t -
r- THE SEPTIC SYSTEM INSTALLATION.
M _ t
ed Coarse 1 . . , _
LOT: ... 109A r •Natural
Gee •Lrcw
-sand # O I
, -----_-.-__—
zs Y 7 4 TEST HOLE t
. - _
_ 95.i0
38 52 O ELEV,- :99.40 ,
Medium
• -W let- ir>e
unreY of a �
Sand > 6 p
• 30
XI TI I E S NG CESSPOOLS TO BE PUMPED i
2.5Y8/4
20 U ED & FILLED IN PLA.E.
Forted
. ..
..• . . , , . , t, -Cesspool
r
NOTE:
E. : ANY. : 0 .. . EX STRIPPED
f I • ISTINC OUT SOIL CONTAINING
CO IN NG LEACHATE
s
_._ _� DR ,a�_ - - FROM .T
�r.. .. >.. 3 if3 OX �- -� .� __. ,. _. __ .. _ E E S NG LEACH TR _.
. , .. _._-- C_ _ BE DISP S .D
0 AS PER AR E BOARD F,H '
0 HEALTHSP
ECIFICATIONS.
Foasd ,;
r HOUSE
�- N
� Ew t500 I.
ess I k - 9a Poa
i
T
I. � Septic onk
; . � ` 39
Pere 1N
Depth Pere:, 1
e to a c. .38 0 56 ,;
P _ r 1\
Per R t
D Box "1
c o e .Less Tho 2 MPI -�
LEGEND
`Groundwater Not Observed
N Observed
o Obse ed ESHWT LOT 232X ,
ADJUSTED H2O flev, - None
SHED
c DENOTES PROPOSE
D
7 000 Square Feet + 104X 1
- i
SPOT GRADE
t_
93.29
S t
O
•Op DENOTES EXISTING
t X 104.46
SPOT GRADE
•
P L
PROJECT N PROPERTY IN BENCH MARK LINE
co ,y
TOP -OF FOUNDATION
LOT #232B ` l-�n�' ,
avr PROPOSED ELEV. 100.00 Assumed OSED CONTOUR ,
- -
EXISTING CONTOUR
;
97 97 CO OUR ;
, LOT #232 pr ,
Failed
Cesspool
ess o o (_
P ,
s TYPICAL 1500 GALLON SEPTIC TANK v►
l_ gUPER - � DEEP TEST HOLE
ST G
U IN
R
M RIT
E W PERCOLATION TEST T NOT TO SCALE t;1NE y IN t ES LOCATION
N►NG VA cstNi ►N gTR►C
cglG tit pND �D
3-24 DIAu. ACCESS MANHOLES. - •::" ,; :. DE TION g[Pa-
STAILA Ag IN
to -6
IN EM W •--=--. 6 FOOT STOCKADE FENCE
, SHE SYST CETO pi.PN C
14 —
z.1,4 . : .:._• , - .- RDA
.. r..
PLO
P LAN
I _
.....�
THE A R ACCESS COVE fOft THE SEPTIC TANK,S E SE C
DISTRIBUTION X AN I
.. �. BO D LEACH NG COMPONENT
OF PROPOS
ED .SEPTIC : SYSTEM
y.n.� .-,�•7••;,� ;�., -.r ..�..,.--,.••.�--,�••. `SHALL'8E RAISED TO wtTH1iJ 6' OF
E UPGRADE
FINISHED GRADE.
PR
EPARED P AR E ED FOR
..STEEL REINFORCEDP
0
RECAST CONCRETE INSTALL TUF TITS GAS BAFFLES OR EOUALS
PLAN VIEW
- ON ALL OUTLET TEE ENDS
E CATHERI NE TOMK NSON
ti AT
#39 TI
Q S ROAD
3 2 REYOVAt11E`COVERS
l HYAN N I S MA
....... . ..... ., , .�,.. . _. . .>,:. Deal nCalculatrons '
q
.}'min. elwance ' 7 �.• f
-n.
1 91L!
6, m
T to out.t INLET ,. _ o R F P P
- ------�----- M EARED BY:
e ma. _ Number of"Bedrooms. Equivalent '(N A 2 ' Equ cent to 220 Gal./Day (330Gol. Da Mtn. per Title V
' OUTLET
` • I Y P ) ,
L id lever
_
Garbage Grinder: N
* ---s r Leaching Capacity Proposed: I � •,
t._ s 9 P Y P 330 Gd./Dby MrrnMum (Min. Title:V
f Septic Tank - x - , ;
. - 4-o m„ �, , P on 3 330 Gol:/Day 660 �JS� t-,50b GAL:-Se tic Tank.`
o..an. 0
Q 0
o ,. wu,d o.p. p ENVIRONM
- SOIL ABSORPTION AREA. Using percolation _ ENTAL' SERVICE
••.. .r Us g pe cototron .rote of <2 min./inch �H: S, INC.
Bottom Area: 74 1 _ � ��.d .. 0 0/s ft. x 360 s ft. 266:4 gallons'- . - No
P.O.
SrdewoflArea: 74 _ I f � �
BOX 627 .
0 o./sq t. x :92 s it. 68.08' ollons
. P` , c- EAST FA
ao-o s -a Providing: 334.48 gallons ,_ S LMOUTH, MA 02536 ,
„ 4. 1
T FA EL X . 50 4 A 8 5 $ 7
.'CROSS. SECTION END—SECTION :.Use. 5 GULTEC,MODEL t IT ' H ..,
SCALE: 1 20 / ass
O 35 UN S• HAVING A 1 °:EFFECTIVE DEPTH, ,, ,
SC 1 _
T i .0 2 BE WITH 4. F> 0 USED 0 0 wAsw T T _, DRAWN > Y WASHED STONE ON HE..SIDES, -AND 3 OF WASHED STONE ,, _ B CES DATE. DUNE 7 2(�03
N THE 0 E ENDS. `N T 0 STONE•. UN
DER.
PR
OJECT SD431 FILENAME
: SD431 PP_OWG SHEET _1 OF