HomeMy WebLinkAbout0045 PINE VALLEY ROAD - Health 45 PINE VALLEY ItD.,HYANNIS
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Pine Valley Road + 1
Property Address
Michael Kayajan t
Owner Owner's Name
information is Barnstable MA 02601 6/9/2020
required for every _
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 jSoy4
on the computer,use only the tab Robert E Buker REHS/RS, CHO
key to move your Name of Inspector
cursor-do not Buker& Sons Title V Services '
use the return
key. Company Name
PO Box 463
Company Address•
Middleborough MA 02346
lawn City/Town State Zip Code
(508) 208-2390 SI/SE 12873
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 personally 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. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DER 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
T
Commonwealth of Massachusetts
Title 5 Official Inspection Form
le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Pine Valley Road
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
page. Cityrrown 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:
System consists of a 1500 gallon, primary treatment tank, a distribution box and four concrete
leaching chambers. System displayed clear flows in all piping and proper hydraulic function and
structural integrity of components on day of inspection.
2) System Conditionally Passes:
❑ One or more tem components as described in the"Conditional Pass" section need to be
replaced or repaI . The system, upon completion of the replacement or repair, as approved by
the Board of Health, 11 pass.
Check the box for"yes", "no" "not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 y s old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or filtration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with omplying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structura sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years of 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
S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
` 45 Pine Valley Road
u
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) yytem Conditionally Passes (cont.):
ump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
p ps/alarms are repaired.
❑ Observat n of sewage backup or break out or high static water level in the distribution box due
to broken o obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspects n if(with approval of Board of Health):
❑ broken pi e(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction i removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box i leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than imes a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval f 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\accordan
determine if
the system is failing to protect public health, safety or the envi -
a. System will pass unless Board of Health determines in10 CMR
15.303(1)(b)that the system is not functioning in a manne 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
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
.- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Pine Valley Road
V
Property Address
Michael Kayajan
Owner Owners Name
information is Barnstable MA 02601 6/9/2020
required for every
page. City/Town 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. Sys will fail unless the Board of Health (and Public Water Supplier, if any)
determine that the system is functioning in a manner that protects the public health,
safety and a ironment:
❑ The system h a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surfac ater supply or tributary to a surface water supply.
❑ The system has a s tic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic nk and SAS and the SAS is within 50 feet of a private water
supply well. .
❑ The system has a septic tank d SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply we **.
Method used to determine distance:
**This system passes if the well water analysis, pe ormed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence ammonia nitrogen and nitrate nitrogen is equal
to or less than.5 ppm, provided that no other failure crit *a 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
Commonwealth of Massachusetts,
Title 5 Official Inspection Form
io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 45 Pine Valley Road
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
El ® 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 1/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 syste ou must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section
Yes No
❑ ❑ the system is with) 00 feet of a surface drinking water supply
❑ ❑ the system is within 200 fee a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen s itive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a p is water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Se Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'. 45 Pine Valley Road
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
page. CityFrown 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?
® El available
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
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6% 45 Pine Valley Road
u
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD
Description:
System design was approved in 1998 to accomadate existing dwelling.
Number of current residents: 3
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 ears usage d Attached
9 ( y 9 (gp ))�
Detail
Records obtained from the Barnstable (Hyannis) water district
Sump pump? ❑ Yes ® No
Last date of occupancy: CurrentDate
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
' 45 Pine Valley Road
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
page. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establish nt:
Design flow(based on 3 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/pe ons/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):
3. Pumping Records:
Source of information: Last pumped in 2019 per homeowner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 45 Pine Valley Road
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
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)
❑ 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 l/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Installed 1999
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1-3 ft(varies because there are 3)
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10 ft.feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
No evidence of leakage or infiltration. Flow test was conducted on all 3 to establish clear flow to
primary treatment tank.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
r _ Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Pine Valley Road
u
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 36 in.
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallon
Sludge depth: 2-3 in.
Distance from top of sludge to bottom of outlet tee or baffle 31 in.
Scum thickness 0-1 in.
Distance from top of scum to top of outlet tee orbaffle in.
Distance from bottom of scum to bottom of outlet tee or baffle 13 in.
How were dimensions determined? Tape measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Structural integrity and hydraulic function of tank were good on day of inspection. Inlet cover is fit with
riser to within 1 ft of grade. Outlet cover is not fit with riser. There are two inlet tees and a single outlet
tee. All in good condition on day of inspection.
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Pine Valley Road
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
7. \Jelow
on site plan):
feet
tion:
❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of\invert,
utlet tee or baffle
Distance from bottomm of outlet tee or baffle
Date of last pumpingDate
Comments (on pumptions, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as relate , eviden a of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inse on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglasslene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day o
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Pine Valley Road
Property Address
Michael Kayajan
Owner Owner's Name
information is Barnstable MA 02601 6/9/2020
required for every
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank t.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:. \switches,
te
Comments (condition of alarm and floa
*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 0 in.
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box in good condition. Fit with riser to within 1 ft of surface.
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
ry Title 5 Official Inspection Form
61"P. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Pine Valley Road
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
page. CityFrown 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: 4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Pine Valley Road
Property Address
Michael Kayajan
Owner Owner's Name
information is Barnstable MA 02601 6/9/2020
required for every
page. Citylfown 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.):
All vegetation was normal and even. No sign of breakout or ponding. Chambers set on shoulder slope
of hill with very well draining soils.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number a configuration
Depth —top of liq id 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 hydrauli failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
45 Pine Valley Road
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (loca\Ian
Materials o
Dimension
Depth of s
Commentsn f hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
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
45 Pine Valley Road
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
page. City/Town 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
Z
Q B
°
e�
3
3 �f
iI
l
t5insp.doc•rev.7/26/2018 /� Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
- 9 p Y rY
45 Pine Valley Road
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
page. City/Town 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: 20 ft.
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: 1998
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:
Permit on file with Barnstable Health District from 1998 describe high groundwater table at 20 ft bgs
according to relevant well data.
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
l0 Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e 45 Pine Valley Road
Property Address
Michael Kayajan
Owner Owner's Name
information is required for every Barnstable MA 02601 6/9/2020
page. CitylTown 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 pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
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Date: 6/10/2020 Meter Reading History Page 1 of 2
Customer# 600255-1
Premise#600255
Service:Water-Regular Metered
METER READING TRANSACTION INFO
Read Date Sequence# Meter# Face Sort # Read Code Reading Consumption Skip Count Type Code Status Bill Period Trans Date
03/03/2020 01 67576578 0 28012060 1 403.00 10.00 0 REG A R 202001 03/09/2020
12/02/2019 01 67576578 0 28012060 1 393.00 13.00 0 REG A R 201904 12/09/2019
09/03/2019 01 67576578 0 28012060 1 380.00 11.00 0 REG A R 201903 09/09/2019
06/04/2019 01 67576578 0 28012060 1 369.00 11.00 0 REG A R 201902 06/10/2019
03/04/2019 01 67576578 0 28012060 11 358.00 14.00 0 REG A R 201901 03/11/2019
12/03/2018 01 67576578 0 28012060 1 344.00 21.00 0 REG A R 201804 12/10/2018
08/27/2018 01 67576578 0 28012060 1 323.00 19.00 0 REG A R 201803 09/03/2018
05/21/2018 01 67576578 0 28012060 1 304.00 19.00 0 REG A R 201802 05/29/2018
02/20/2018 01 67576578 0 28012060 1 285.00 20.00 0 REG A R 201801 02/25/2018
11/20/2017 01 67576578 0 28012060 1 265.00 17.00 0 REG A R 201704 12/05/2017
08/21/2017 01 67576578 0 28012060 1 248.00 27.00 0 REG A R 201703 09/04/2017
05/22/2017 01 67576578 0 28012060 1 221.00 16.00 0 REG A R 201702 06/04/2017
02/23/2017 01 67576578 0 28012060 1 205.00 18.00 0 REG A R 201701 03/02/2017
11/21/2016 01 67576578 0 28012060 1 187.00 24.00 0 REG A R 201604 12/06/2016
08/23/2016 01 67576578 0 28012060 1 163.00 27.00 0 REG A R 201603 09/01/2016
05/23/2016 01 67576578 0 28012060 1 136.00 18.00 0 REG A R 201602 06/05/2016
02/22/2016 01 67576578 0 28012060 1 118.00 20.00 0 REG A R 201601 03/03/2016
11/19/2015 01 67576578 0 28012060 1 98.00 24.00 0 REG A R 201504 12/07/2015
08/25/2015 01 67576578 0 28012060 1 74.00 25.00 0 REG A R 201503 09/02/2015
05/27/2015 01 67576578 0 28012060 1 49.00 22.00 0 REG A R 201502 06/02/2015
02/18/2015 01 67576578 0 28012060 1 27.00 17.00 0 REG A R 201501 03/01/2015
11/25/2014 01 67576578 0 28012060 1 10.00 10.00 0 REG A R 201404 12/02/2014
09/30/2014 01 38388158 0 28012060 1 3,076.00 6.00 0 REG A O 201404 09/30/2014
09/30/2014 01 67576578 0 28012060 1 0.00 0.00 0 REG A S 201404 09/30/2014
09/05/2014 01 38388158 0 28012060 1 3,070.00 40.00 0 REG A R 201403 09/22/2014
05/30/2014 01 38388158 0 28012060 3 3,030.00 20.00 0 REG E R 201402 06/10/2014
02/26/2014 01 38388158 0 28012060 1 3,010.00 30.00 0 REG A R 201401 03/05/2014
11/25/2013 01 38388158 0 28012060 3 2,980.00 70.00 0 REG E R 201304 12/04/2013
08/29/2013 01 38388158 0 28012060 3 2,910.00 60.00 0 REG E R 201303 09/04/2013
06/04/2013 01 38388158 0 28012060 3 2,850.00 20.00 0 REG E R 201302 06/05/2013
02/26/2013 01 38388158 0 28012060 3 2,830.00 30.00 0 REG E R 201301 03/07/2013
11/27/2012 01 38388158 0 28012060 1 2,800.00 30.00 0 REG A R 201204 12/05/2012
08/28/2012 01 38388158 0 28012060 3 2,770.00 25.00 0 REG E R 201203 09/05/2012
.f 05/30/2012 01 38388158 0 28012060 1 2,745.00 20.00 0 REG A R 201202 06/07/2012
02/29/2012 01 38388158 0 28012060 1 2,725.00 25.00 0 REG A R 201201 03/07/2012
Date: 6/10/2020 Meter Reading History Page 2 of 2
Customer# 600255-1
Premise#600255
Service:Water-Regular Metered
METER READING TRANSACTION INFO
Read Date Sequence# Meter# Face Sort # Read Code Readinq Consumption Skip Count Type Code Status Bill Period Trans Date
11/28/2011 01 38388158 0 28012060 3 2,700.00 73.00 0 REG E R 201104 12/05/2011
O8/29/2011 01 38388158 0 28012060 1 2,627.00 95.00 0 REG A R 201103 09/07/2011
06/01/2011 01 38388158 0 28012060 3 2,532.00 22.00 0 REG E R 201102 06/10/2011
03/01/2011 01 38388158 0 28012060 3 2,510.00 22.00 0 REG E R 201101 03/09/2011
12/01/2010 01 38388158 0 28012060 1 2,488.00 28.00 0 REG A R 201004 12/14/2010
09/09/2010 01 38388158 0 28012060 3 2,460.00 50.00 0 REG E R 201003 09/17/2010
06/04/2010 01 38388158 0 28012060 3 2,410.00 24.00 0 REG E R 201002 06/10/2010
03/03/2010 01 38388158 0 28012060 1 2,386.00 24.00 0 REG A R 201001 03/10/2010
12/07/2009 01 38388158 0 28012060 1 2,362.00 22.00 0 REG A R 200904 12/11/2009
09/09/2009 01 38388158 0 28012060 3 2,340.00 40.00 0 REG E R 200903 09/21/2009
06/09/2009 01 38388158 0 28012060 1 2,300.00 14.00 0 REG A R 200902 06/29/2009
03/06/2009 01 38388158 0 28012060 1 2,286.00 20.00 0 REG A R 200901 03/06/2009
12/02/2008 01 38388158 0 28012060 1 2,266.00 26.00 0 REG A R 200804 12/02/2008
09/01/2008 01 38388158 0 28012060 1 2,240.00 31.00 0 REG A R 200803 09/01/2008
06/03/2008 01 38388158 0 28012060 1 2,209.00 23.00 0 REG A R 200802 06/03/2008
03/04/2008 01 38388158 0 28012060 1 2,186.00 23.00 0 REG A R 200801 03/04/2008
11/29/2007 01 38388158 0 28012060 1 2.163.00 33.00 0 REG A R 200704 11/29/2007
09/11/2007 01 38388158 0 28012060 1 2,130.00 29.00 0 REG A R 200703 09/11/2007
06/11/2007 01 38388158 0 28012060 1 2,101.00 21.00 0 REG A R 200702 06/11/2007
03/05/2007 01 38388158 0 28012060 1 2,080.00 25.00 0 REG A R 200701 03/05/2007
12/05/2006 01 38388158 0 28012060 1 2,055.00 35.00 0 REG A R 200604 12/05/2006
09/06/2006 n1 38388158 0 28012060 1 2,020.00 20.00 0 REG A R 200603 09/06/2006
06/05/2006 01 38388158 0 28012060 1 2,000.00 20.00 0 REG A R 200602 06/05/2006
03/08/2006 01 38388158 0 28012060 1 1,980.00 0.00 0 REG A R 200601 03/08/2006
12/02/2005 01 38388158 0 28012060 1 1,950.00 0.00 0 REG A R 200504 12/02/2005
f�
�s
No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
f Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
application for Mioozat *proem Construction Permit
Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) IR Complete System ❑Individual Components
Location Address or Lot No. y5 Owner's Name,Address and Tel.No.
J air
Assessor'sMap/Parcel `erZi
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
7?�s �
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(�
Other Type of Building ✓L�� f L��G�No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ///> gallons per day. Calculated daily flower gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 16 eW Type of S.A.S. 'V—5�l_e9P G liras
Description of Soil Ap�ele
oer ,
Nature of Repairs or Alterations(Answer when applicable) thvle Z7
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 Certifi-
cate of Compliance has been issued this oard o Health. ��
Signed .'' Date /0</1,0*
Application Approved by <S Date 10-1 c/ �
Application Disapproved for the ollowmg reasons
Permit No. �� — 6 Date Issued
^ —
No. Fee C� /
�—_ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. ✓/
Yes
PUBLIC HE LTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS
ZlppYicatton for Diopoal *pgtem Construction Permit
Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) L Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,; ddress-and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
BOe'�dLorf`iLv�S�' ,\
7 7�-9.399
Type of Building: u
Dwelling No.of Bedrooms / Lot Size sq.ft. Garbage Grinder
Other Type of Building 12�,s% �1C C No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 2WO gallons.
Plan Date Number of sheets Revision Date -
Title
Size of Septic Tank /:S D� Type of S.A.S..
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 Certifi-
cate of Compliance has been issuedby this Board o Health. ��
Signed Date 1 er
Application Approved by Date I
Application Disapproved for the ollowing reasons'T1 l
iJ
p i A
Permit No. O — 6 3 Er Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( ✓)Upgraded( )
Abandoned( )by /Y/ /J / L'Oi95T 7 NG
at y &N� l/D' lel /y has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date - Inspector �
/ � — ��� -----------------Z�� %� s No. �Fee �
THE COMMONWEALTH OF MASSACHUSETTS �/
PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS
Migpogaf *pgtem (Cou5tructiou Permit
Permission is hereby granted to Construct( )Repair(V,�,' rad ( )Abandon( )
System located at y� /��" y4���y- !�� ///�f9il/.
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: L "/ ' / Approved by "
l0/9/97
NOTICE This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
ld2/�, hereby certify that the application for disposal works
construction permit signed by me dated /O//"'; , concerning the
property located at meets all of the
prop y
following criteria:
/There are no wetlands located within 100 feet of the proposed leaching facility
ere are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
�✓ If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will llQt be located less than fourteen (14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map)
B)Observed Groundwater Table Elevation(according to Health Division well map) ZD
SIGNED: DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE.TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder.cert
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