HomeMy WebLinkAbout0021 PRAM ROAD - Health 21 Pram Road
Hyannis
A = 268 042
TOWN OF BARNSTABLE
LOCATION Z 9 Praq-,\ Roo. SEWAGE# 2019 - t4$L,
VILLAGE ASSESSOR'S MAP&PARCEL 2L$ '- 42
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY JSOO ``
LEACHING FACILITY:(type) So0q�l,�c (,z. (size) 13)(2.5 A 2-
NO.OF BEDROOMS 3
OWNER lJ i d!S'r,*A p c C2
PERMIT DATE: 12. Z q. 19 COMPLIANCE DATE: J- 2'7. 2 O
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
Al ' �32
Az 5o lei
'
A3 Gy'S
M - Gs, 7 3
23 ; O O
REA R
TOWN OF BARNSTABLE
LOCATION loZ1 Prarn F0G d SEWAGE #
VILLAG ASSESSOR'S MAP & LOT aid S'* O"l
�ii'S NAME&PHONE NO. 6k'ad nt �C5)7�'S l•t/�S,O�P�.1
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS 3 -�-
84adm� OWNEROb�r� .l • AG'l7lJ'e.
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�I
REAR OF HOUSE
A 8
PRIMARY CESSPOOL
A-1=3IT
8-1=44'
2 OVERFLM CESSPOOL
A-2=22'
B-2=85'6"
Commonwealth Of Massachusetts
Executive Office Of Environmental Affairs
Department Of Environmental Protection
TITLE 5
Official Inspection Form -Not For Voluntary Assessments
Subsurface Sewage Disposal System Form
Part A
Certification
Property Address:21 Pram Rd.Hyannis Ma.02601
Owners Name:Robert J.Macon J
Owners Address:21 Pram Rd.Hyannis Ma.02601
Date of Inspection:4/8/2006
Name of Inspector(please print)Sean M.Jones f
Company Name: S.M.Jones Title V Septic Inspectors ti ,
Mailing Address: 74 Beldan Ln.
Centerville Ma.02632 �U
Telephone Number.508-7784597
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:
X Passes
Conditionally Passes
Needs further evaluation by the Local Approving Authority
Fails
Inspectors Signature Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board`of Healk 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 ofithe
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,acid the approving r j
authority. - _I
�f
Notes and Comments:This dwelling is served by the original cesspool and overflow cesspool system. co
X- M
""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.
Page 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address:21 Pram Rd.Hyannis Ma.02601
Owner:Robert J.Macon
Date of Inspection:4/8/2006
Inspection Summary: Check A,%C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:N/A
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 enfiltration or the 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 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 pipe(s)are replaced
obstruction is removed
ND explain:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(coNTmm)
Property Address:21 Pram Rd.Hyannis Ma.02601
Owner: Robert J.Macon
Date of Inspection:4/8/2006
C.Further Evaluation is required by the Board of Health:N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
Is failing to protect public health,safety or the environment.
1.System will pass unless Board of health determines in accordance with 310CMR 15.303(l)(b)that the
System functioning in a manner that protects the public health,safety and the environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
Surface water supplyor tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone i of a public water supply.
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:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address:21 Pram Rd.Hyannis Ma.02601
Owner:Robert J.Macon
Date of Inspection:4/8/2006
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of cesspool or privy is within Zone 1 of a public well.
X Any portion of cesspool or privy is within 50 feet of a private water supply well.
X Any portion of 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 pp,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
X (Yes/No)The system fails.I have determined that one or more of the above 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:N/A
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:
Yes No
T the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you 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
CM15.304.The system owner should contact the appropriate regional office of the Department.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:21 Pram Rd.Hyannis Ma.02601
Owner: Robert J.Macon
Date of Inspection:4/8/2006
Check if the following have been done.You must indicate` es"or"no"as to each of the following_
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of system components pumped out in the previous two weeks?
_X _ Has the system received normal flows in the previous two week period?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding SAS,located on site?
X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tee,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_X _ 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
X_ Existing information.For example,a plan at the Board of Health.
_X_ _ 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)]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:21 Pram Rd.Hyannis Ma.02601
Owner: Robert J.Macon
Date of Inspection:4/8/2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):-3— Number of bedrooms(actual):_3_
DESIGN flow based on 310 CMR 15.203(for example): 110 gpd x#of bedrooms): 330 GPD
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no):—No [if yes separate report required]
Laundry system inspected(yes or no)_N/A
Seasonal use:(yes or no) NO
Water meter readings,if available(last 2 years usage(gpd): 2004/2005=85,500 gallons— 119GPD
Sump pump(yes or no): No
Last date of occupancy/use:_Current_
COMMERCIAL/INDUSTRIAL:N/A
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sg8,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:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons—How was this quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
_X_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 the 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: 1968+/-
Were sewerage odors detected when arriving at the site(yes or no): No
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:21 Pram Rd.Hyannis Ma.02601
Owner:Robert J.Macon
Date of Inspection:4/8/2006
BUILDING SEWER(locate on site plan)
Depth below grade: 2.5`Bleow TOF
Materials of construction:_X_cast iron 40 PVC other(explain): Orangeburg
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
Joints were in good condition,no sign of leakage.
SEPTIC TANK:—N/A—(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 a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
As related to outlet invert,evidence of leakage,etc.):
GREASE TRAP: N/A (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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:21 Pram Rd.Hyannis Ma.02601
Owner:Robert J.Macon
Date of Inspection:4/8/2006
TIGHT or HOLDING TANK: N/A (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:_N/A (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: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:21 Pram Rd.Hyannis Ma.02601
Owner:Robert J.Macon
Date of Inspection:4/8/2006
SOIL ABSORPTION SYSTEM(SAS)_X_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
Leaching pits.Number:
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
leaching fields,number,dimensions:
_X_overflow cesspool,number:-I
innovative/alternitave system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Soil was dry,vegetation was normal.At time of inspection overflow cesspool had F of standing water with a
stain line approximately 2,higiLer.
CESSPOOLS:-N/A (cesspools 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: N/A (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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:21 Pram Rd.Hyannis Ma.02601
Owner:Robert J.Macon
Date of Inspection:4/8/2006
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 5'`+/-below cesspool
Please indicate(check)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:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
High groundwater was determined by accessing Town of Barnstable groundwater contour map.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:21 Pram Rd.Hyannis Ma.02601
Owner:Robert J.Macon
Date of Inspection:4/8/2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or
Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building
REAR OF HOUSE
A B
PRIMARY CESSPOOL
A-1=31'6"
B-1=44'
2 OVERFLOW CESSPOOL
1 A-2=22'
B-2=85'6"
i
No. / "/ Fee Q�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
applitation for MispoBal *pstem Construction VPrmit
Application for a Permit to Construct( ) Repair(,A Upgrade( ) Abandon( ) [Complete System ❑Individual Components
Location'Address or Lot No. 21 Praarn F�oAd ,Nyanni S Owner's Name,Address,and Tel.No.WA t'e do Qlet}e Z
Assessor's Map/Parcel Mc1 p V v$ I y1 21 Pre,,,, Road 6o.c n M t b1v, JAo
Installer's Name,Address,and Tel.No. (3 3 I3 ^Lx a o vo.t%oc%Inc Designer's Name,Address,and Tel.No.Fla her+%,
;Rom-e. IS ScxnA' ,Lh /Ao. OZ5(o3 PO (30x S11
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size 1 I13y0 sq.ft.+ Garbage Grinder(No)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3�j gpd Design flow provided 3 4% gpd
Plan Date 12.1 1-if 19 Number of sheets Z Revision Date
Title
Size of Septic Tank 1500 cgkon Type of S.A.S. (1) $00 O,,,kk0r, Gho.mb"rs
Description of Soil See, 9l ails
Nature of Repairs or Alterations(Answer when applicable) 660, ko:,led ceSS0001S WI ISUO An'\kon SZ.
d- box a„a sAS.
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 Health. °
S' ed Date ,
Application Approved by . Date
Application Disapproved by Date
for the following reasons
Permit No. J � Date Issued
No.
Fee
t 11no
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Apphration for Misposal 6pstetn Construction Permit
Application for a Permit to Construct( )' Repair(, Up&ade - Abandon( ) [Complete System ❑Individual Components
Location Address or Lot No. 7► Pr a M {��o d ,1=1� nn+; Owner's Name,Address,and Tel.No.W; c e P 1 C,i- Z
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. 6 {j �x G v�,� ,,,,., �n c. Designer's Name,Address,and Tel.No-7-1 c,be r 4�a
3�� �jc�)+ e 13(1 �c,nrlw,C,1� :/"fie. �ZS(D3 PO box 331 4e.rw,(�, PAC", OZl-oaS
Type of Building:
Dwelling No.of Bedrooms Lot Size ,3�{(} sq.ft4/. Garbage Grinder(N o)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) o gpd Design flow provided y gpd
Plan Date 1�_1 q Number of sheets �_ Revision Date
Title
Size of Septicank Type of S.A.S. Z J� u r1,r,mk,r c
Descri tion of Soil
p
Nature of Repairs or Alterations(Answer when applicable) )epNn(9 �Ae 6 c ec.!��nr,!c r /1>_00 gs 11 r,r,
& SAS. J
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 Health.
Signe Date ,
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 'y' Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliante
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(✓) Repaired( ) Upgraded( )
Abandoned( )by
at 71 P r ca c„ 17,nn r1 o,g s has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit N;dQ gated
Installer .�o 3 `t�(r n v a},+l n Designer r 1,a r k, pl k
#bedrooms Approved design flow 1 3y Q, gpd
The issuance of this permit shall not be construed as a guarantee that the system wil ptt n as desi d.
Date I I a t) Inspector ( _,
= - -------- ------------,--------------------------- --------- ----------------------.-----------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construction Permit
Permission is hereby granted to Construct( �) Repair( ) Upgrade( ) Abandon( )
System located at �
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 permi
Date /����/Z Approved by
Town of Barnstable
�TME, Inspectional Services
Public Health Division
ientesrnaL&
NAM Thomas McKean,Director
i639.
�ba 200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 1 28-- Sewage Permit# Zo19 - y8G Assessor's MaplParcel 2G$ - t42
Designer: 3oakcri�4 ErJy',rornce%Ao J Installer: 1A 4 C3 Excg_uo-A;o�
Address: Pa So)( �i31 Address: J9 TcaScrrs Lo,3
F-oreSido� C
On 12•Z N- 19 S3 i,4 rXe .yo. i o✓� was issued a permit to install a
(date) (installer)
septic system at 21 Pram\ � based on a design drawn by
(address)
due dated 12-19- 19
(designer)'
___�L I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils.
were found satisfactory..
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' .lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State& Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed i E ee with the to rms of
the AA approval letters(if applicable) ssa
moo? DAVID oyG�
o D.
FLAHERJY,JR.
(I tall er'TSnatdw,� No. 1211GisTF-
SgNtTWP�
esigner's Signatur (Affix Designer's Stamp Here)
PLEASE RETURN TO.BARNSTABLE PUBLIC HEALTH.DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION..
THANK YOU.
WoMdeptAHEALTMSEWER conneeMEPTICOesigner Certification Form Rev 8.14-13.DOC
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 21 Pram Road
Property Address ?
William &Carolyn McCarty
Y Y
Owner Owner's Nam r,
information is H annis Ma 02601 5-15-17 „
required for every Y p',
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. General Information �'� ,
- : -
on the computer,
use only the tab 1. Inspector:_
key to move your
cursor-do not Matthew Gilfoy
use the return
Name of Inspector
key.
B&B Excavation -
rab Company Name
374 Route 130 ...
Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113640
Telephone Number . License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the.inspection..The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes. ❑ Conditionally Passes ❑ Fails
❑ Needs.Further Evaluation by the Local.Approving Authority
5-15-17
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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.:..
****This report only describes conditions at the time of inspection and under the conditions of use.
at that time.This inspection does not address how the system will perform in.the future under
the same or different conditions of use. -
t5ins•3/1,3 Page 1 of 17
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
.. �04 4d V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Pram Road
Property Address
William & Carolyn McCarty
Owner Owner's Name
information is required for every Hyannis Ma 02601 5-15-17
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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.-
In working order at time of inspection. Cesspools were pumped as part of inspection as per
requirements with no indication of groundwater inflow.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
N
t .
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 21 Pram Road
Property Address
William & Carolyn McCarty
Owner Owner's Name
information is required for every Hyannis Ma 02601 5-15-17
_
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 21 Pram Road
Property Address
William & Carolyn McCarty
Owner Owner's Name
information is required for every Hyannis Ma 02601 5-15-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 21 Pram Road
Property Address
William & Carolyn McCarty
Owner Owner's Name
information is required for every Hyannis Ma 02601 5-15-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 21 Pram Road
M
Property Address
William & Carolyn McCarty
Owner Owner's Name
information is
required for every Hyannis Ma 02601 5-15-17
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): No design Number of bedrooms (Actual) _3
plans
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°.H 21 Pram Road
Property Address
William &Carolyn McCarty
Owner Owner's Name
information is
required for every Hyannis Ma 02601 5-15-17
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d See below
9 ( Y 9 (gp ))�
Detail:
2016-3,740gallons 2015- 5,236gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
NA
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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora'
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Pram Road
Property Address
William &Carolyn McCarty
Owner Owner's Name
information is Hyannis Ma 02601 5-15-17
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Inspector
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 400
gallons
How was quantity pumped determined? Sight glass on truck
Reason for pumping: Inspection of cesspools
Type of System:
❑ Septic tank, distribution box, soil absorption system
® Single cesspool
® Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 21 Pram Road
Property Address
William &Carolyn McCarty
Owner Owner's Name
information is
required for every Hyannis Ma 02601 5-15-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Unknown due to lack of record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18
feet
Material of construction:
❑ cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town
feet
.Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: NA
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 21 Pram Road
Property Address
William &Carolyn McCarty
Owner Owner's Name
information is
required for every Hyannis Ma 02601 5-15-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: NA
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Pram Road
Property Address
William & Carolyn McCarty
Owner Owner's Name
information is required for every Hyannis Ma 02601 5-15-17
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
it
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 21 Pram Road
Property Address
William &Carolyn McCarty
Owner Owner's Name
information is required for every Hyannis Ma 02601 5-15-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert NA
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
.If SAS not located, explain why:
d
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
6'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 21 Pram Road
Property Address
William &Carolyn McCarty
Owner Owner's Name
information is Hyannis Ma 02601 5-15-17
required for every y
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: 6'x8'
❑ 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.):
Over flow cesspool (2na cesspool in series)was dry at time of inspection with no sign of past back up.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 2 in series
Depth —top of liquid to inlet invert 3
Depth of solids layer 9
Depth of scum layer 0
11
Dimensions of cesspool 6'x8'
Materials of construction blocks '
Indication of groundwater inflow ❑ Yes 0 No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
cM 21 Pram Road
Property Address
William &Carolyn McCarty
Own
er er Owner's Name
information is required for every Hyannis Ma 02601 5-15-17
_
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Cesspools were working at time of inspection with no sign of hydraulic failure.
Privy (locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Pram Road
Property Address
William & Carolyn McCarty
Owner Owner's Name
information is required for every Hyannis Ma 02601 5-15-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
REAR OF HOUSE
A B
Ai-31'6° B1- '
A2.22' 82.60'
2 1
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Pram Road
Property Address
William &Carolyn McCarty
Owner Owner's Name
information is required for every Hyannis Ma 02601 5-15-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >5
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:
Past inspection report where contours maps were used was okay per BOH agent.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Information on file with BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 21 Pram Road
Property Address
William &Carolyn McCarty
Owner Owner's Name
information is required for every Hyannis Ma 02601 5-15-17
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
L _
e�
COVERS TO BE WATERTIGHT AND SEPTIC SYSTEM PROFILE Flaherty Environmental Services
TOP OF FOUNDATION BROUGHT TO WITHIN 6"OF FINAL GRADE (not to scale) "
EL. 58.0 EL. 56.0 INSP. PORT W I 3 OF GRADE CLEAN SAND P.O. BOX 331
2" of��i" DOUBLE WASHED EL. 56.0' Harwich, MA 02645
4" CAST IRON or EQUIVALENT PEASTONg-OR GEOTEXTAE 774.994.1166
MIN. PITCH 1/4" PER FOOT FILTER FABRIC ;
46 SCHEDULE PVC PIPE 4°SCHEDULE 40 PVC PIPE VENT IF REQUIRED
FLOW LINE (hUs12•tObB/Bv�
• 7' 3.2% 5' 1% '
°°o°o°°oc
o
• o 0 0 0
L5 .9' 14- 1 0000000 ® 0000c
E-`+a•0' 53.75' —� —i°" o°o°o°o°o° o .o o°o°o°o°c
EL.53.03' o00000 0 0°0°0°0° ®�o o°o°o°o°e 2.W
3 2' ° o°o°o°0°000° 0 0 0 0
o000000o �® ®��� ® o00oc—
�0 MIN. 2.5% EL. 3.0 00oo000000 000000 w 000000°oc
GAS BAFFLE (H-20D•B0� o00000000° o00000 ;a' • d .. °o°o°o°oc EL 51. '
6"CRUSHED STONE OR SOIL ABSORPTION SYSTEM l
"• •''•':`':.`' MECHANICALLY Y COMPACTED (2) 500 GALLON H-20 CHAMBERS s,S
(DATUM: ASSUMED) �_� WITH 4'STONE AROUND IN A _ S
1500 GALLON SEPTIC TANK 4" to 1," DOUBLE WASHED STONE 12.83'X 25'X 2'CONFIGURATION s' L 5
(PROPOSED) BOTTOM OF TEST HOLE EL. 4t' EL. 4 '
USGS ADJUSTMENT: N/A coOanavMAP
GROUNDWATER ELEV: N/A BHs
Wd
BENCHMARK: QUA QA'
TOP OF FNDN
12.6 EL. 58.0'
TH-2 TH-1 -
�.� 85
Rd
56 CP
{�0 34.5
= o r A ,
OD N LOCUS
11.6 CP I NM
EXISTING
10.0, 3 BR v W $ gyp OF A4,4 -
DWELLING D `/
r
NO
OSH F 211 .
F
SHED PORCH 187E
�4AIITAt;��'� r
DRIVEWAY
LOT 5 _ Jr
11,340 SFt
MAP 268 PLOT 42 DATE f2HSfrZ019 REVISED:
100.
,LEGEND 56 SITE AND SEWAGE PLAN
FOR
-6 6 6 \8 GAS LINE B & B EXCAVATION, INC./
-W �,r W �wATER LINE WILFREDO PLEITEZ
E E E XIST. ELECTRIC 2I PRAM ROAD
SCALE . = HYANNIS BARNST ABLE MA
,
99 EXIST. CONTOURS • �� 30
————— 99 PROP. CONTOURS
1-149 11.49 UNDERGROUND UTIL.
REF.-PS 212 PG 61 PAGE i Oi2
GENERAL NOTES DESIGN'CALCULATIONS YSTEM DETAIL Flaherty Environments/ Services
S _.
1. ALL PRECAST COMPONENTS TO BE H-10 P. O. Box 331
�r RATED UNLESS OTHERWISE SPECIFIED. HemfiCh, MA 02645
DISTRIBUTION BOX AND ANY NUMBER OFACTUAL BEDROOMS 3 774.994. 166
COMPONENTS WITH ANY ANTICIPATED t.
VEHICULAR TRAFFIC TO BE H-20 RATED. GARBAGE DISPOSAL UNIT NO
2. THE DESIGN OF THIS SYSTEM DOES NOT
ALLOW FOR THE USE OFA GARBAGE TOTAL ESTIMATED FLOW
GRINDER. (110 GALIBRDAYX 3 BR) 330 GALADAY
3. MUNICIPAL WATER IS AVAILABLE. REQUIRED SEPTIC TANK CAPACITY 660 GAL.
4. ALL CONSTRUCTION TO CONFORM WITH 25'
310 CMR 15.000 AND ALL OTHER SIZE OF SEPTIC TANK 1500 GAL. (PROPOSED)
APPLICABLE LOCAL, STATE AND FEDERAL
CODES AND REGULATIONS. SOIL CLASSIFICATION 1
5. INSTALLERICONTRACTOR TO REVIEW&
VERIFY ALL ELEVATIONS AND DETAILS DESIGN PERCOLATION RATE <2 MINANCH
.•4
AND REPORT ANY DISCREPANCIES TO 0 74 GAL.IDAYIFT2
DESIGNER PRIOR TO CONSTRUCTION OR
EFFLUENT LOADING RATE Q O 12.8 3'
ASSUME ALL RESPONSIBILITY. LEACH/NG AREA
6. INSTALLER/CONTRACTOR IS (2)x(25.0'+ 12.837(27 =151 SF
RESPONSIBLE FOR MAINTAINING SAFE 25.0'x 12.83' =320 SF
WORK AREA, VERIFYING ALL UTILITIES 471 SFx 0.74 =348 GPD
AND NOTIFYING "DIG SAFE"
(1-888-344-7233) 72 HOURS PRIOR TO USE(2)600 GALLON H-20 CHAMBERS WITH 4'STONE
CONSTRUCTION. INA 12.83'X25'CONFIGUR4TIONASD14GR4MMED
Z ANY CHANGES TO OR DEV1 A77ONS FROM
THIS PLAN MUST BE APPROVED IN RESERVE LEACHING CAPACITY N/A
WRMNG BY FLAHERTY ENVIRONMENTAL
SERVICES AND LOCAL BOARD OF
HEALTH.
8. FINISH COVER OVER COMPONENTS IS
NOT TO EXCEED 3'PER 310 CMR 15.000
UNLESS SHOWN PER PLAN. (NTS)
9. ALL ABANDONED SEPTIC SYSTEM
COMPONENTSMP TO BE PUMPED DRY AND E
FILLED WITH CLEAN SAND OR REMOVED SOIL EVAL UA TION
AND REPLACED WITH CLEAN SAND. TESTHOLE51 TPV 19.234 TESTHOLEA2 T773R 18234 �' '
10.ALL COMPONENTS TO BE PROVIDED Evaluator` DOWD.Flaho*Jr.,RS,REHS EvaluatorDevklD.Flet►ertyJr.,Rs,REHs
WITH WATERTIGHT ACCESS PORTS SE#2755 i SE#2755
WITHIN 6".OF FINISH GRADE. BOH w�ew: Dav/d Stanton,Rs BOH WWm D*W sianton Rs
Date., December 19,2019 Deb., December 19,2019 11.ALL SEPTIC TANKS, DISTRIBUTION
BOXES AND PIPING TO BE INSTALLED n
WATERTIGHT, TH-1 ELEV 580' TM2ELEv 58.0' G/STERN
12.N0 KNOWN WETLANDS OR WELLS 01-101 A Ls 10YRW 0•-10' A LS 10YR32 tTARt0.N t [�
WITHIN 150 FEET OF PROPOSED
LEACHING.
13.THIS IS NOT A CERTIFIED PLOT PLAN �o•-z9• a Ls 10rR s✓e �. 10•-29• a Ls 1oYR s✓a
AND UNDER NO CIRCUMSTANCES IS THIS
PLAN TO BE USED FOR ZONING OR l aer&V tint on November 12,2002.1 have passed SITE AND SEWAGE PLAN
BUILDING PURPOSES. Pic the exam/namon approved by&a Depwft"of FOR
14.LOT IS SHOWN AS ASSESSOR'S MAP 268 Env/ivn ►m/Protection and that the above analya�e
LOT 42. has been byme pD1��'n"�'ft B & B EXCAVATION, INC-/
29°-12r C MS 2.5Yff 2r-120° C MS 2.5YQ/8 re9u/redbalMng,expe>t/se,andexpertenoedeacrtbed WILFREDO PLEITEZ
15.LOCUS PROPERTY IS LOCATED WITHIN + In 310 CMR 15.018(2).
AN AQUIFER PROTECTION DISTRICT !_ 21 PRAM ROAD
(ZONE II). (HYANNIS) BARNSTABLE,
G.W.ELEV.WA G.W ELEV.NA MA
BOTTOM TH-1 EL 45.5' BOTTOM TH-2ELEV. 46.0'
PAGE20F2 DATE.•12119MIO
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