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HomeMy WebLinkAbout0064 PONTIAC STREET - Health 64 Pontiac Street Hyannis A= 269-188 i rag Commonwealth of Massachusetts a y1 Title 5 Official Inspection Form ,a i�l Subsurface Sewage Disposal System Form =Not for Voluntary Assessments, X. 64 Pontiac St Property Address , Cara O'Dell s f_ Owner Owner's Name C17 information is Hyannis MA 02601 4-11-19 ` required for every I-• i, 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. A. Inspector Information 5!4t a3 Shawn Mcelroy Name of Inspector. Upper Cape Septic Services Company Name P.O. Box 73 _ r Company Address E. Falmouth MA 02536 Cityrrown State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000);l have personally inspected the sewage disposal system at theproperty 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' • s 2. ❑ Conditionally,Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 4-11-19 I Spector'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 DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts y Title 5 Official Inspection"Form �-I Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments 64 Pontiac St Property Address Cara O'Dell Owner Owner's Name information is Hyannis required for every MA 02601 4-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary - Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes-' ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure•criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. t . 2) System Conditionally Passes: ❑ One,or more system components as described in the "Conditional Pass"*section need to be �. replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y - ❑N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts r ,'. Title 5 Official Inspection Form "I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Pontiac St Property Address Cara O'Dell Owner Owner's Name information is required for every Hyannis MA 02601 4-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with-approval of Board of Health): ' t ❑ broken pipe(s) are'replaced ❑ Y ❑N '❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ 'ND (Explain below): t Rk R L _ r ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect'public health, safety or the enviionment.' - a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.W26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 e+ .1. Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form .I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Pontiac St Property Address Cara O'Dell Owner Owner's Name information is required for every Hyannis MA 02601 4-11-19 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. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered:A copy of the analysis must be attached to this form. c. Other: , 4) System Failure Criteria Applicable to All Systems: You';nust 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 , 3 Title 5 Official Inspection Forme , iclF Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r e 64 Pontiac St ;t. Property Address Cara O'Dell Owner Owner's Name information is required for every Hyannis MA 02601 4-11-19 . - 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_ abovebutlet 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 Y2 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. y ❑ ® 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 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 CA._ Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts y Title 5 Official Inspection Form I�I w:1 • r�l. Subsurface Sewage Disposal System Form Not for Voluntary Assessments - 64 Pontiac St Property Address Cara O'Dell Owner Owner's Name information is required for every Hyannis MA 02601 4-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) t 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 t 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 ®.I ❑ Pumping information was provided by the owner, occupant, or Board of Health El ® 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? ❑, Z. Have large volumes of water.been introduced to the system recently or as part of this inspection? ' R 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 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? ` r Wasthe 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 4' , Commonwealth of Massachusetts r� Title 5 Official Inspection Form 0 i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Pontiac St _ Property Address Cara O'Dell Owner Owner's Name information is required for every Hyannis MA 02601 4-11-19 - page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? _ ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ' ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 4- 019 Date t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts r 3 Title 5 Official Inspection Form- pi. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Pontiac St Property Address Cara O'Dell Owner Owner's Name information is required for every Hyannis MA 02601 4-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ' 2. Commercial/Industrial Flow Conditions: Type of Establishment: J. Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: . Date Other(describe below): 3. Pumping Records: Source of information: Owner--pumped 5 yrs ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c 1 Commonwealth of Massachusetts fia r Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Pontiac St _ Property Address Cara O'Dell Owner Owner's Name information is required for every Hyannis MA 02601 4-11-19. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system: _ r ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2010 Were sewage odors detected when arriving at the,site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18"feet ' Material of construction: ❑ cast iron ' ' ® 40 PVC "El other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts = _ - 3 Title 5 Official. Inspection Form wa MI. Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 64 Pontiac St Property Address Cara O'Dell Owner Owner's Name information is required for every Hyannis MA 02601 4-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): r• r Depth below grade: .. 12" feet Material of construction: L ® 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: 1000 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1-r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 64 Pontiac St Property Address Cara O'Dell Owner Owner's Name information is required for every Hyannis MA 02601 4-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: - feet Material of,construction: ❑ concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: j Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts - fw Title 5 Official Inspection Form Subsurface Sewage Disposal System Form :Not for Voluntary Assessments ' 9 p Y rY 64 Pontiac St Property Address Cara O'Dell Owner Owner's Name information is Hyannis • r MA 02601 4-11-19 required for every page. City/Town State Zip,Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) "Alarm present: ❑ Yes El No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: t ' Date " Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be;opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc•rev.7/26/2018 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form m p 0�4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Pontiac St Property Address Cara O'Dell Owner Owner's Name information is required for every Hyannis, MA 02601 4-11-19 . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . 10. Pump Chamber(locate on site plan): Pumps in working order: " ❑ Yes ❑ No* Alarms in working'or'der: ❑ 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. A 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: 2-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments W 64 Pontiac St Property Address Cara O'Dell Owner Owner's Name information is Hyannis ' 1 MA 02601 4-11-19 required for every y page. City/Town 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.): Leach chambers in good condition and empty at inspection with no visible stain lines. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration - a Depth-top of liquid to inlet invert - Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes • ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts f- Title 5 Official Inspection Form r " I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Pontiac St Property Address Cara O'Dell Owner Owner's Name information is required for every Hyannis MA 02601 4-11-19. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 13. Privy (locate on site plan): r Materials of construction: Dimensions Depth of solids Comments (note condition.of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts y Title 5 Official. Inspection Form Hr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p y rY 64 Pontiac St Property Address Cara O'Dell ' Owner Owner's Name information is Hyannis - MA 02601 4-11-19 required for every page. City/Town 7, 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 1. 177 :b r m .s t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form %I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Pontiac St Property Address Cara O'Dell Owner Owner's Name information is Hyannis - MA 02601 4-11-19 required for every y ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . 15. Site Exam: ❑ Check Slope a ❑ Surface water ' ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 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-1 50 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: Original design plans show no groundwater at 12'. 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 cam` Commonwealth of Massachusetts Title 5 Official Inspection Form 01 Subsurface Sewage Disposal:System Form -Not for Voluntary Assessments 64 Pontiac St Property Address Cara O'Dell Owner Owner's Name information is required for every Hyannis MA 02601 4-11-19 page. City/Town 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 Jan 26 10 06: 01p Col1een Mason, (5081 833-2177 p. 1 'down Of Barnstable -r Regulatory Services y � Thomas F.Geller,Director + � s Public Health Div)GSion Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508. Installer &Designer Certification Form Date: Designer: I /1 Q Installer:' F Address: . iq,51 5 Address: In l V-7 _ _��_�o 5 On .� �as issued a permit to install a (date) (installer) septic system at J04 112014n uk( , based on a design drawn Loy (address)7- dated (design.er) eerrxfy that the septic system referenced above was installed substan"tially according.� die desiM which may include minor approved changes such as lateral idlocation of tl d 'i'bntion box and/or septic tank I cexiifyP that the septic system nferenced above was ins ect vtiith' }M changes greater than 10' lateral xelocation•of the SAS or-any vertical-reoc�iiun of any compote of the.sept�`agWem)but m accordance with State&Local Plan.revisian�< certified as hizllt'by desaer to follow. Q=� D&VIE) Onstaller s Signature} r S• cn MASON sgNl7'-A s Signature} ( = .e ea's stamp Here) PLEASE RETURN TO 11A1tr4.1q+ �.E�PUBLIC.HEAL1'D DIYISIOk�T_ C -Tl OFF COMPjANCE yVII&j= off-` &E �FEIItM AASS $TILT=LAID ARE RECMEI?BY I B SABLE PURL _$E IBy][SIUN THANK YOUt Q:Health/Septic/Designer Certification i:on:;' TOWN OF BARNSTABLE LOCATION ®�Ti.4c J SEWAGE# S VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. 0i"P7 �"�o �/i� 77 f- SEPTIC TANK CAPACITY LEACHING FACILITY.(type) X r� � NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: — p Separation Distance Between the: 'y® Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility f' 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 1 l "r No. a d o — O S Fee ( " THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rppfltatlon for Bisposal 6pstritt Construction 3offmit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System �,Individual Components Location Address or Lot Nox!5y,OV"s+7_1.4 C_ .J>>- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. ®707 ;ti7j Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -:2 -2 o gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 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 Certificate of Compliance has been issued by this Board of He Signed n Date Application Approved by Date j Application Disapproved by Date for the following reasons Permit No. �10 10 0 Date Issued t': rr .• �F •Y No. d 0 0 00 t.7 t -Fee THE COMMONWEALTH,OF MASSACHUSETTS Entered in comuter: Yes R� = PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS" 2ppfiration for ]Bisposai 6psirm Construrtion permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot'No.,40-' t1 C J�i /�y. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures -Design Flow(min.required) o gpd Design flow provided Zs%. Sao d gP Plan Date—-' Number of sheets "I Revision Date Title t ° Size of Septic Tank p, ,9,41 Type of S.A.S. J'R`ce` ��,��•- (' Description of Soil a Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: i The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Signed Date Application Approved by Date Application Disapproved by Date for the following reasons J Permit No. 1_9 U t© 00 S Date Issued " f l 6 ------------------------------------------------------------------------------------------------------------------------------------- - ' - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(\'4 Upgraded,( ) Abandoned( )by S�s� ���oEl/�'� n at C2ro' T/,4G _J'T- .y,.`�,�iviJ' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.a 0 G —OGS dated �" It_ 1 0 Installer,_ '-'si3 ���oe�`!/,e` Designer,d.Irii� #bedrooms Approved design flow p� Q gpd The issuance o[.a this permit shall not be construed as a guarantee that the system w'\t i.Inctibn)as design . Date � j �� Inspector Cy Av ------------------------------------------ ----- - - No. aq 010— 005 Fee 1 THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION-_BARNSTABLE,MASSACHUSETTS Misposar &pstrm Construction permit Permission is hereby granted to Construct( ) Repair Upgraded`O Abandon( ) System located at 6'".S� .�sv7�1,IG .J'T, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit._, _ Date ��—1C) Approved by U m Town of Barnstable P# Department of Regulatory Services a�twarnet8 Public Health Division Date l 200 Main Stieet,Hyannis MAs02601 - "Y� Date Scheduled oho . r Time . �OU Fee Pd r Soil Suitability Asses •ent for S7Lisosal Performed B :�J, O �"� Y ee;c� Witnessed By: S�fivtn LOCATION& GENERAL INFORMATIO Location Address 6 y �p wy j�C f�T . Owner's Name ge r k 4X An 41 f Address Assessor's Map/Parcel: (9 q - �'� Engineer's Name NEW CONSTRUCTION REPAIR �/ • Telephone# Land Use 10US� Slopes(40) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft• Drinking Water Well �— ft Drainage Way ft Property Line ft Other SKETCH:(Street name,dimensions of lot,exact locations of est holes&pert tests,locate wetlands in proximity to holes) t . 2 [ Parent mate (geologic) `�V 1�-)�CS Depth to Bedrock OD Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in, Depth to soil mottles: in. Depth to weeping from side of obs.hole: ~ in, ©roundwater Adjustment ft. Index Well# Reading Date: Index Well level a-_ Adl.factor Adj,Groundwater Level I PERCOLATION TEST bite Titne,,o�,._ Observation Hole# Time at 9" e Depth of Pere Z2 Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Rate Min./inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) i Original: Public Health Division Observation Hole Data To Be Completed on Back=---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the ' Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. consistency, v - 2 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. . Consistencv.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel - •I DEEP OBSERVATION HOLE LOG Hole# Depth from .Soil Horizon Soil Texture Soil Color Sol] Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Consi ten Flood Insurance Rate Map: Above 500 year flood boundary .No— Yes - - - Within 500 year boundary No Yes ' Within I00 year flood boundary No,v Yes Depth of Naturally Occurring Pervious Material Does'at least four feet of naturally occurring pervtou ma rial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of nat rally occumng pervious material? Certification I certify that on �D q (date)I have passed the soil evaluator examination approved by the Department of Environ enta Protection and that the above analysis was 1 e or Ted by me consistent with .. the re fired training, x er' n e pe ence described in 310 CMR 15:01 . Signat e Date 1 7 Zo 1d r , Q-.\sEPT]0PERCFORM.DOC I TOWN Old B WSTABLE. IC?CA'�'iON VYLLACrs � ✓1/E. i S Ai.S5'ESS�R'S INSTA RZt'S NAME&P3EIGPtB No. cAEvcz cA Acicx Spa s LtAdONG J. W.ILT€'Y:,.(t a). y �O tDI7��+DtLOt;33EVtS. t]ILfC1F,1�OR OAR; PBRI�tgT`33A.' � cor. r�GE : .:.._.._. T._,�.... ,._ .:. .' Maximum Ajus !GrauIadwstra' able to tha Bcuotn ot' t.echin kuibt�i ON P�Iv I4tc ii Ey Whit asi.d L.w in arility +f�m Y�rslls exist an$Etc ce wdthitt?Op`fast dP:EiaacEii fac�Ilt}�) Fast P.ci r of �let4atid and lLe6416$ 1*0 ty;�oy'w�tEantls e�us4 flee r�}�tais�3U{1 het teac��ingladltcy, :: / r � r �o , GJ SU r ASSESSORS MAP _:_, � - -- -- - - TEST HOLE LOGS NOTES: PARCELS� .__ ,�__._.�_.,.�_w._._....�--_.��__��.u____.___-_.__-_._ h� t� SOIL EVALUATOR I k)/I M �!1 Gc FLOOD ZONE: �,/ / -�. L- ___.___. ----- WITNESS : Y - -` ~� ---- 1) The installation shall comply with Title V and Town of Barnstable Board of REFERENCE: #( l ` ''i_ m_`4 — -- DATE: Health Regulations. r-Z, PERCOLATION RATE: I 2) The installer shall verify the location of utilities, sewer inverts and septic components prior to installation and setting base elevations. �j 10 w 3 All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first TH_ I TH-2 ) �' Y p p p g two feet out of the d-box to the leaching shall be level. l ,lj lA IJ6' 4 This plan is not to be utilized for roe line determination nor any other ° I I 2� ( ) purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over H10 septic components. LOCATION MAP ZZ 7) The property is bounded by property corners and property lines. 8) The property owner shall review design considerations to approve of total 1� design flow and number of bedrooms to be considered for design. Receipt yrt of payment for the plan and installation based on the plan shall be deemed I YM 10 17 approval of the design flow by the owner. I �� 9) The existing leaching or cesspools shall be pumped and filled with material a,} �3 per Title V abandonment procedures. Those within the proposed SAS shall 1 , be removed along with contaminated soil and replaced with clean sand per -- - _- - Title V specs. ak:' 2 M 10)System components to be 10 feet from water line. Sewer lines crossing the SEPT I C� SYSTEM DESIGN water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. The proposed SAS is being installed below the water-service line. The line is to be sleeved as aforementioned and maintained in place. FLOW, ESTIMATE 11) If a garbage grinder exists it is to be removed and is the responsibility of the j owner to ensure such. 2- BEDROOMS AT P 10 GAL/DAY/BEDROOM -l)GAL/DAY 12)The installer is to take caution in excavation around the gas line if such exists. 13)The installer shall verify the location, quantity and elevation of the sewer SEPTIC TANK lines exiting the dwelling prior to the installation. I GAL/DAY x 2 DAYS - CD D GAL - -- r Imo. 1--170,:f; - - USE GALLON SEPTIC TANK ..SOIL 6 ORPT I ON�SYSTEM� (Z-) ,ro'% e> cettq,5 - Jyl Ib nn r 6 g I 14•! l l SIDE AREA: G1. 4 (3 ����� �, e D BOTTOM AREA: = � tA,SOrq • ` — ' - - � Flo,In E-P-T-4-C S Y S T EM SECT I ON o ZD+� I0 . . TV Ia 0 Willy �, 0` D-BO 3,Z jc' Q �IDOC) GAL .� 14 ► 3, _ T SEPTIC TANK V4 >b LI�V1lI �j t I s � # I 03 DP 1 V Pb — �.� SITE AND SEWAGE PLAN ForI PREPARED FOR : R SCALE: 11112-0 DAV I D B . MASON,"►,, DATE: I W DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA z - 2 177 DATE HEALTH AGENT ( SO8 ) 833 w S w z