HomeMy WebLinkAbout0034 RABBIT LANE - Health 34 Rab.1it Lane
Hyannis
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Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w„ 34 Rabbit Lane
Property Address
Eric Kallesten
Owner Owner's Name
information is or
West H annis t. MA 02672 04/01/12
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.release 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:
ikeyto move your
cursor-do not Michael'Kellett
use the return Name rof Inspector
key.
(► me� Aardvark Environmental.Inspections
y Company Name
.PO Box 896
Company Address
East Dennis MA 02641
Cityrrawn State Zip Code
508-385-7608 SI 3742'
Telephone{Number License Number
B. Certification
I certify that.I have personally inspected the sewage disposal,system at this address and!that the
information reported below is true,accurate and complete as of the time of the inspection.The inspection
was performed based on my.training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR-15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
04103/12
Inspector's Signature Date
The system inspector shall submit 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 inspectorrand the-system owner shall submit the
report to the appropriate regional office of the DER The original should be sent to the system owner
and copies sent to the;buyer,cif applicable,and the approving authority.
***This report only describes conditions at thetime.of inspection and'under the conditions-of use
at that time.This;inspection does not address hfow the system will:perform in the future under '
the same or different conditions of use.
Lu
t5ins•11/10 Tdle`50fficialln• Inspection F :S urface'Sewage Disposal System•Page 1 of 17
41
Commonwealth.of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System,Form-Not for Voluntary Assessments
w 34 Rabbit Lane
Property Address
Eric Kallesten
Owner Owner's Name
information is.required for every West Hyannisport.r MA 02672 04/01112'
page, City/Town 'State Zip Code Date of Inspection
:B. Certification (coat
Inspection Summary:Check A,B,C,D.or EJ always complete all of Section.D
A) System Passes:
® 1 have not found any information which:indicates that any of the failure criteria described
in 310 CMR 15303 or in 310 C'MR 15.304 exist.:Any failure criteria not evaluated are
indicated'below.
Comments:
B) System ConditionallyPasses:
❑ 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 Boardz of Health,will pass.
r
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(whethermetal or not)is structurally
unsound,exhibits substantial infiltration orexfiltration 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.
*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
10 Y ❑ N. ❑ ND(Explain'below):
F 5 F
t5ins•11/10 A '. Title 5 Official Inspection Form:Subsurface.Sewage'Disposal System-Page 2 of 17 4, . e
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Commonwealth of Massachusetts
Title 5 Official: Inspection Farm
Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments
34 Rabbit Lane
Property.Address
Eric Kallesten
Owner Owner's Name
information is required for every West Hyannisport. MA 02672 04[01/12.
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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 wilt
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.
M 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 mannerwhich will protect public health,
safety and the environment:
❑ Cesspool;or,privy is:within 50:feet of a surface.water
El Cesspool or privy is within.50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 _ Tide 5 Official Inspection Form:Subsurface Sewage Disposal,System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Rabbit Lane
Property Address .
Eric Kallesten
Owner Owner's Name
information i e
required for every West Hy p annis ort MA 02672 04/01/12.
page. City/Town State Zip Code Date of Inspection
B. Certification (coot.)
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 septiatank 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 but50':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
col form 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 orsurface waters
due to an overloaded or clogged SAS or cesspool I
_ F
❑ ® 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°ibelowlinvert or available volume is less
than 1/2 day-flow
t5ins•11/10 , 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
34 Rabbit Lane
Property Address
Eric Kallesten:
Owner Owner's Name
information is required for every West Hyannisport MA 02672 04101/12'
page. Cityrrown 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 00 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.
❑ N 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.]_
❑ 2 The system is a cesspool serving a.facility with a design flow of 2000gpd-
10,0009pd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 GMR 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 15000 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
E] El Area
system is located in a nitrogen sensitive area:(Interim Wellhead Protection ,
Area IWPA)or a mapped Zone 11 of a public water supply well.
If you have answered "yes."to any question in Section E the system is considered ar 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-11/10 Tine 5 ofrpial Inspection:Form:Subsurface Sewage Dsposa6 System•Page 5 of 17
f
Common-wealth of Massachusetts
Title 5 Official Inspection Form:
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
34 Rabbit Lane
Property Address
Eric Kallesten
Owner Owner's Name
information is required for every West Hy P annis ort. MA 02672 04/01/12
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as,to each ofthe following:
Yes No
® ❑ Pumping information was;provided by the owner, occupant,or Board of Health
❑ E Were any of the system components pumped out in the:previous two weeks?
® ❑ Has the system receivedt 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 ofthe system obtained and examined? (if they were not
available:note as N/A)
® ❑ Was the facility or dwelling inspected forsigns 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 ofthe 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): 3 Number of.bedrooms(actual)::. 3
DESIGN:flow based:on 31:0:CMR 15.203 (for example: 1 TO gpd x#of bedrooms): 330 .
t5ins•.11/10 -. Tittle Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Su,bsurface Sewage Disposal System Fo m-Not for Voluntary Assessments
34 Rabbit Lane
Property Address
Eric Kallesten
Owner Owner's Name
information is West H annis ort MA 02672 04/01/12.
required for every y p
page. City/7own State Zip Code Date of'Inspection
D. System Information
Description:
Numbenof,current residents: 2
Does residence have a garbage grinder? F-11 Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required]: Ell Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last2 years usage(gpd)):.
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercialfindustrial Flow Conditions:
Type of Establishment:
t
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. .
F '
Water meter readings,if available:
t5ins•11/10 Title.5Official Inspection Form:Subsurface Sewage D'sposai''.Systern-Page 7 of 17
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Commonwealth.of Massachusetts
Ti he 5 Official Inspection Foam
s Subsurface Sewage Disposal System Form—Not for Voluntary Assessments
34 Rabbit Lane
Property Address
Eric Kallesten
Owner Owner's Name
information is West H annis ort. MA 02672 04/01/12'
required for every y p
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:
Was system pumped as part of the inspection? ❑, Yes ® No
If yes,volume pumped.: gallons
How was quantity pumped determined?
Reason forpumping:
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 1/A system by system operator.under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe): 4
t5ins•11/10 - TRIe.5Official InspecUon.Form:Subsurface Sewageoisposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System'Form-Not for Voluntary Assessments
w 34 Rabbit.Lane
Property Address
Eric Kallesten
Owner Owner's Name
information is required for every West Hyannisport MA 02672. 04/01'/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components,date installed (if known)and source of information:
06/10/03 per BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2.3
Depth below grade: feet
Material of construction:
❑cast iron 2 40.PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting,evidence of leakage,.etc.)
Septic Tank(locate on site plan):
Depth below grade:' 1.7
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; 1000 gal
4"
Sludge depth:
t5ins-11/10 - Title 5Official Inspection Form:Subsurface'Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official tnspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
34 Rabbit Lane
Property Address
Eric Kallesten
Owner Owner's Name
information is required for every West Hy p annis ort MA 02672. 04/01/12
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 28"
Scum thickness 3"
Distance from top of scum to top of outlet tee oribaffle 5
Distance from bottom of scum.to bottom of outlettee or baffle 15"
How were dimensions determined? measured
Comments(on pumping recommendations.,inlet and outlet tee or baffle condition,structural integrity,
liquid levels.as:related'to outlet invert,evidence of leakage, etc.):
The tank was sound and tight with tees in place and liquid at outlet invert.
Grease Trap(locate on site plan):-
Depth below.grade: feet
Material of construction:
❑concrete 0 metal 0.fiberglass ❑ polyethylene 0 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 ofJast:pumping; Date
t5ins-11/10.. _ Title 5 Official Inspection Form::Subsurface Sewage Disposal System-Page 10 of 17 "
Commonwealth:of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage:Disposal System Form-Not for Voluntary Assessments
34 Rabbit Lane
Property Address
Eric Kallesten
Owner Owner's Name
information is required for every West Hy p annis ort MA 02672 04/01/12.
page. City/Town 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 belowgrade:
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.)::
"Attach copy of current pumping.contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 50fficial Inspection Form:Subsurface-Sewage.Disposal.*.stem•Page 11 of 17
r
Commonwealth,of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-'Not for Voluntary Assessments
34 Rabbit Lane
Property Address
Eric Kallesten
Owner Owner's Name
information is required for every West Hyannisport MA 02672 04/01/12
page. CityTrown 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 outiet.invert even
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.):
The box was level and tight with no sign of carryover.
Pump Chamber(locate.on site plan):.
Pumps in working order: ❑ Yes ❑ No
Alarms in wo:rking.order. ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Soil Absorption System.(SAS)(locate on site plan,excavation not required).-
If SAS not located,explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface SewageDisposallSystem, Page-12 of 17 _ +
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-'.Notfor Voluntary Assessments
34'Rabbit Lane
Property Address
Eric Kallesten
Owner Owner's Name
information is required for every West Hy p annis ort MA 02672 04/01/12
page. City/Town State Zip Code Date of Inspection
D. System Information (coot.)
Type:
❑ leaching pits, number-
chambers' number: 2
❑ leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields• number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding.,dampr soil,condition of
vegetation,etc.):
This system has two•500 gallon drywells in a•24'xl X field of stone.There was no sign of ponding or
failure in the stones
Cesspools,(cesspool:must be:-pumped.as,part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet(invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of•construction
Indication of;groundwater,inflow ❑ 'Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:.Subsurface-Sewage�Disposal:System-Page 13 of 17 `
Commonwealth of Massachusetts
Title 5 Official Fnspectidn Form
s Subsurface Sewage Disposal System Foam Not for Voluntary Assessments
34 Rabbit Lane
Property Address
Eric Kallesten
Owner Owner's Name
information is required for every west Hy p annis ort MA 02672 04/01/12'
page. City/Town 'State Zip Code Date of Inspection
D. System 71 nformation (cont.)
Comments(note condition of soil,signs of hydraulic failure,.level of ponding,condition,of vegetation,
etc.):
Privy(locate on site plan)::
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil',signs of hydraulic failure.,level of ponding,condition of vegetation,
etc.):
I .
t5ins-11l10 Title Official inspection Form:Subsurface Sewage Disposal System Page 14 of 17 .
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Commonwealth of massechusetts
Fills 5 Official Inspection Foggy
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Rabbit Lane
Property Address +
Eric Kallesten fi
Owner Owner's Name. (
information is every
West H nnis ort
MA-
required for eve ya p MA 0267Z I 04101/12
page. Cityfrown 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.Locale all wells within 100 feet.Locate
where public water supply enters the building.Check one of the boxes below:
i
® hand-sketch in the area below
[] drawing attached separately
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i5fis•11/10, Tiue.5 Official tnspedon Fo _Subsurface Sewage Disposal System.Page 15 of 17
{
i
Commonwealth of Massachusetts
WTitle 5 Official; Inspection Form
Subsurface Sewage Disposal System,Form-Not for Voluntary Assessments
'.0 34 Rabbit Lane
Property Address
Eric Kallesten
Owner Owner's Name
information is required for every West Hy p annis ort MA 02672 04/011121
.
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
20.0
Estimated depth to high ground,water: feet
Please indicate all imethods;used:to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design.plan reviewed: Date
❑ Observed`site(abutting property/observation hole within.150 feet of SAS)
❑ Checked With local'Board of Health—explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USES database-,explain:.
You must describe howyou established the high groundwater elevation:
USG S maps show an,elevation of over 20.0 feet.
Before,filing this'Inspection Report,'please see Report Completeness Checklist on next page.
t5ins-11/10 - Title 5 Official Inspection Form:Subsurface Sewage.Disposal System-Page 16 of 17
e
Commonwealth,&Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposa[System.Form-Not for Voluntary Assessments
34 Rabbit Lane
Property Address
Eric,Kallesten
Owner Owner's Name
information is West'Hyannisport 'MA 02672 0410111.2
required for every
page. City/Town State Zip-Code Date of Inspection
E. Report.Completeness Checklist
® Inspection'Summary:A, B, C, D,•orE checked
® Inspection Summary 1D(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 fife
e '
t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 17 of 17
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4
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 34 Rabbiticys c
Property Address
Paul Fogarty
Owner Owner's Name
information is Hyannis MA 02601 August 1 2007
required for y g
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your David D. Coughanowr Z� y4 0 to
cursor-do not Name of Inspector
use the return
key. Eco-Tech Environmental y� 3
Company Name
rac 43 Triangle Circle
Company Address
Sandwich MA 02563
erwn City/Town State Zip Code
508 364-0894 1328 ,
Telephone Number License Number
I rs
B. Certification r
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 mai ttenance,of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to section 1:5.34050f
Title 5 (310 CMR 15,000). The system:
OD r�
® Passes ❑ Conditionally Passes ❑ Fail
❑ Needs Further Evaluation by the Local Approving Authority
August 1, 2007
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.
t5-2724.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is required for Hyannis MA 02601 August 1, 2007
every page. City/Town 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:
® 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:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
i
❑ obstruction is removed
t5-2724.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is required for Hyannis MA 02601 August 1, 2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (corgi
❑ 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:
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
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.
t5-2724.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is Hyannis MA 02601 August 1 2007
required for y g
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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 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.
t5-2724.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is Hyannis MA 02601 August 1 2007
required for y g
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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-
10,000g pd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large 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
IJ El 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.
t5-2724.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is required for Hyannis MA 02601 August 1, 2007
every 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)]
t5-2724.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is Hyannis MA 02601 August 1 2007
required for y g
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
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: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 541 gpd
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
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): — —
t5-2724.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is required for y g Hyannis MA 02601 August 1' 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Age: 4 years. Failed leach pit replaced with gallery in 2003 (Board of Health files).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
f
t5-2724.doc.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is Hyannis MA 02601 August 1 2007
required for y g
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer appears structurally sound with no evidence of backup or leakage into dwelling
Septic Tank (locate on site plan):
Depth below grade: 2
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:
8.5ftx5ftx5ft(1000gallon)
Sludge depth:
3 in
Distance from top of sludge to bottom of outlet tee or baffle 31 in
Scum thickness 2 in
Distance from top of scum to top of outlet tee or baffle 9 in
Distance from bottom of scum to bottom of outlet tee or baffle 13 in
As built card
How were dimensions determined?
t5-2724.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
f-
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is Hyannis MA 02601 August 1 2007
required for y g
every page. City/Town 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.):
Pumping not required at this time but maintenance pumping is recommended within and every two
years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage
in or out was observed.
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.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
f ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t5-2724.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is Hyannis MA 02601 August 1 2007
required for Y g
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert At outlet inverts
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.):
D-box appears structurally sound with no evidence of leakage in or out. Few solids in sump.
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
I
t5-2724.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is required for y g Hyannis MA 02601 August 1' 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number:
1
❑ leaching trenches number, length:
❑' leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name.of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into
the distribution box and was observed to pass through in a rapid and unobstructed manner, and could
be heard splashing down into the leaching gallery.
t5-2724.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is Hyannis MA 02601 August 1 2007
required for y g ,
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5-2724.doc•08/06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 15
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is Hyannis MA 02601 August 1 2007
required for y g
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
LEACHING
GALLERY
LOCATIONS
0 2
0 o-eox A B C
I 28 ft 3.5 ft
2 65.5 fE 39 ft
I
9 SEPTICC o TANK
A
EXISTING
DWELLING
# 34
w
z
J
(Y
W
F
3
RABBIT ROAD NOT TO SCALE
t5-2724.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Rabbit Road
Property Address
Paul Fogarty
Owner Owner's Name
information is Hyannis MA 02601 August 1 2007
required for y g
every 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 ground water: 30+feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
Refer to Board of Health files
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database - explain:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Approved design plan on file with the Board of Health shows bottom of system to be 5 feet above the
bottom of a witnessed test pit in which no water was encountered. Town of Barnstable GIS
Department records indicate that the property is over 30 feet above groundwater table.
i
t5-2724.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
i
Town of Barnstable
�p 1HE rp�
Regulatory Services
BARNSTABLE,
Thomas F. Geiler, Director
9$A b r Public Health Division
TFD MA'S A
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fak: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
TOWN OF BARNSTABLE
L&CATION * ;4- Lt ' SEWAGE #
Y,MLAGE Y YA)" ASSESSOR'S MAP & LOT-Q-�J
INSTALLER'S NAME&PHONE NO,.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) size) '
NO.OF BEDROOMS
z-
BUILDER OR OWNER U L J-TZt`(
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:.
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility)) Feet
Furnished by Lee)- T F.CH (TV5 P)
1
LEACHING
GALLERY
z LOCATIONS �.
❑ 0-BGX
A B C a
1 28 FE 3.5 FE 1
2 65.5 FE 39 Ft
i
a SEPTIC
c TANK jI
o i
A
EXISTING
DWELLING
# 34 !
W
Z
w
w
I 3
NOT TO SCALE
RABBIT ROAD
No. Fee,
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
• Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS
01pplication for Zioagal 6potem Con6truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. �q�b �, l-� r wner's e, ddress and Tel.No.
Assessor's Map/Parcel
Installer's Name Address,and Tel.No. / Designer's Name,Address and Tel.No.
��/V �BNSUdUCOiQW J-dS� �� 9�'
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder Alp
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ,� 3� gallons per day. Calculated daily flow Q gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank lO®0 %15, Type of S.A.S. 3-00 eAC dc'`
�S d
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ens u3e t c ' n and maint n ce of the afore described on-site sewage disposal system
in accordance with the provis' s of Title 5 o ron ental de and not to place the system in operation unti a 7fi-
b
cate of Compliance has b n i ued e 6 (O
Sign Date
Application Approved by Date
Ile) &5
Application Disapproved or the ollowing reasons
Permit No. Date Issued
a l
w No., Fee
x
L. t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
a .} PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSEM
01pprication for Zitpont *p5tem Construction Vermit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 3 q�6,` �. A.-, 9 r , Owner�ame,Address and Tel.No.
Assessor's Map/ParcelG U I � Y
a� 3
Installer's Name,Address,and Tel.No. T Designer's Name,Address and Tel.No.
1 ou C e /'
�ofr • -'o7�
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 �� �� gallons per day. Calculated daily flow 0 gallons. j
Plan Date Number of sheets Revision Date
Title r
Size of Septic Tank I o Sr*r Type of S.A.S. co ` SO 0 X EAC
fs
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement: 1 r
The undersigned agrees to ensure.the-con truc i nand mainten ice of the afore described on-site sewage disposal system
in accordance with the provissjo�Title 5 0 n ron ental de and not to place the system in operation unti a)rti fl-
cate of Compliance has b n' ued b rlilr o e t io
Sigh-o Date_
Application Approved by /77 go Date
a . Application Disapproved for the f to lowing reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CE.TIF)(,t at the n-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( )
Abandoned( )by _ + -
�_ - y ljas constructed in accordance--
with the provisions of Title 5 and the for Disposal S stem Construction Permit N . dated -0 3
Installer Designer VT
The issuance of fli6l
s ermit shall not be construed as a guarantee that the system ,il f�a es' ed
Date rl Inspector
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
MiqogaY *pgtem Con5truction hermit
n
Permission is hereby granted to Coons ct )Repair( Up ade Q )Abando )
System located at j� Ic' p r � /
9 IN LS;
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and//the following local provisions or special conditions.
Provided: C nst�uction fnu t bej mpleted within three years of the date of this opermit.Date- 1.J Approved by �
TOWN OF BARNSTABLE
LOCATION ?9A/olxrml .441,/ SEWAGE #
VILLAG 1: /.E ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. .L y �►...5
SEPTIC TANK CAPACITY - /010 O
LEACHING FAC]LrrY;(type) (size) 2- SVC
NO.OF BEDROOMS 3 _
BUILDER OR OWNER � Oe'
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottomof 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
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L-10 CAT ION / / SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME 6 ADDRESS
B UILDER OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED15.
W
y
°O
04
.a
No, Fm:B
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............�..OF........ ........................
Apptiration for Disposal Works Tonstrurtion rumit
Application is hereby made for a Permit to Construct (>' ) or Repair an Individual Sewage Disposal
System at:
cam--. ..... �41_6.1... ................................a.*.......................................................
Loca io ,Address or Lot No.
- 12 ------------- ------------------------I---------- - ---------------------------------------------------
............. C__Jtn�4
Address
.5..f....................................................
_0 --- ----------------------------------------- ...............................a
in'staller Address
Type of Building Size Lot---10 QX ....L Sq. feet
.
U
Dwelling—No. of Bedrooms..........X............................Expansion Attic/(A Garbage....ge Grinder WO)
a
Other—Type of Building _ .Lx........... No. of persons.......... ............... Showers (,2,) — Cafeteria (All
Otherfixtures ......A/". ..4. ............................................................................................................................
Design Flow............ .......................gallons per person per day. Total daily flow.........S ..0......................gallons.
9 Septic Tank—Liquid capacity,&l.t0gallons Length.....1.4..... Width__..........._ Diameter-----k------- Depth.....e.......
Disposal Trench—No..................... Width.................... Total Length__.................. Total leaching area...J_6
X------sq. ft.
Seepage Pit No.-AM Diameter.................... Depth below inlet.._................. Total leaching area..................sq. ft.
Z Other Distribution box Dosing tal ( )F 6 4, Date.....Percolation Test Results Performed by ...ce-d
L A:
Test Pit No. I.....25�.-.2-,minutes per inch Depth of 4est Pit....T.2...... Depth to ground wate'r... -----.......
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......_____..._...._._._
............................................................................................................................................................
0 Description of Soil_----- ....... .........
�4 -1) X--------------------------------------------------------------------------
.............................................................
--------------------------
............................... ...... 4.,X.......N L�_b------ ......................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.....................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'LI`I1Z 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
n5eration until a ertificate of pliance has been issued/by the board of health.
io i
d. . . ......................
igne ... .. ..............
D fp
p PI ti pp Y..
lication Approved By........ . . ......q).-p ... ........................... ......... ......
te
Application Disapproved for the following reasons:................................................................................................................
........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
N ,
No._ .....�o... Fss.. ... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................OF.....
,.h .................................................
Applirttiiun for 11iipuuttl Workii Tunitrnrtiun Famit
Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal
System at:
.. - ........• Location -Address
V�• ..._....... ................................ •-Lot No._----------------------...... .........
Location-Address or
r _... I ( n �............................................r �c.............--•--•-----•................................_-•••-
Owner Address
Installer Address
U Type of Building Size Lot... .......Sq. feet
Dwelling—No. of Bedrooms.......... -------------------------------Expansion Attice(l,,.) Garbage Grinder (U�,)
Other—Type of Building �� r%'� `f yp g ....:.....:...............•--No. of persons.__._._.r_.__.__..._._.__.. Showers (A ) — Cafeteria (f✓✓)
Q Other fixtures .._.. ..i��...... _...
------•--•-----.---••......•-••-•......•--•-------••-•-•--••-••-•••-•-•--•-----••-•-••-----•---•--•---------•--
W Design Flow.......... .........................gallons per person per day. Total daily flow--------- . _. ......................gallons.
WSeptic Tank—Liquid capacity!r'_�gallons Length----!� __.._.. Width......6........ Diameter__._t...______- Depth.... .........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area__:%L_`Z......sq. ft.
Seepage Pit No............ 4---- Diameter.................... Depth below inlet.................... Total leaching area............_.....sq. ft.
Z Other Distribution box V, ) Dosing tank ( ).
~' Percolation Test Results Performed by.:LZj........................... , .... Date.... ._ �_/`_ ........
Test Pit No. 1.....C:.r.�Kminutes per inch Depth of (Test Pit--- _....... Depth to ground water---)J/'"J�___._..
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a .-•--•-----•-•--------•--•-••---•-•-•••---•--•--•-•--••••----•---••......--.....•---.....--•-.-----•.........................................................
O Description of Soil......L-..�____...__l^:.__.it- �_ ...!, � I
- --------------------•--------------------------------•--------------------------•-----.....--------•-
-_.. ._' C. , -:�r t tip, 1 , � 7 s`3
W ---•••-•---••-------................. .-_----`-•..................--....------... ......J' -•----•---------------------------------------------------•-----------------------...------------•-•-•
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
----------•---------------•------------•-...---------•--------------....------........-------•------•--------------------------------------------•-----------•-------•--••-•----------....._•••••-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
S Signed �j-•----------•-----------------••-•-•----•.
.
Da ... ........
Application Approved By......... ', = _ _:_ . 4? 1.........-•----•---•-•... �� �� ------
"ate
Application Disapproved for the following reasons:-----------•---------------•-•------------------------•------------------------•-------------------------•-•---
---------------------------------------------•--------------•---••-------•-----•--...------------------•.-••---••........---•-----••-•••••--•--------••••-------•---•••••--•--•-•••••--••---•--•...-•---
Date
PermitNo......................................................... Issued.....................................................-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF! HEALTH
�.
��ertif irtt#r of �unt�littnr�e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by - ------�=-----='--- '-`----------------------------------------------- ---------- ..........................
-
Installer ,
---•-••••---•-----•-•-••-•• ---------------:-------------------------------------•--------------------------------•--•-----------
has been installed in accordance with the provisions of TITS` ,5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.......... '_.6__________________ dated-...............................................
THE ISSUA CE OF THIS CERTIFICATE SHALL NOT EE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL 'FUNCTION SATISFACTORY.
DATE................ .. ....................................... inspector:...................... `-- . ----- . . ..............................
THE COMMONWEALTH OF MASSACH ETTS
BOARD OF HEALTH.
�. __ l _
......... ..�0..............OF......:.. r� n l J. �'.rU.::r.........:........_......_............
No.- •••••. FEE.._.....•...............
Disposal IVorkn Tungt//r iun famit
Permission is hereby granted...___.-.�L1. ..... ...................................
_..
to Construct( ) or;Repair ( !) an Individual Sewage Disposal System
at No.. -••-••••.?1'`7 X, '  L,1'iG'Y._... //.I ,ate
Street'
as shown on the application for Disposal Works Construction Permit No._: ': '_ Dated....._._�__2.1
.................
---•----•--•----
DATE-----_off_.__-.-�. Board of Health.
FORM 1255 A. M. SULKIN, INC., BOSTON
2q. +
IS
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AffU
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dRSE
,No.
10951
74. �FF.,�SIONA1 �a�
LEGEND
1 EXII-STING .SPOT ELEVATION OAO t E'LDRE�Or_. r
E'XQ93`TIG ® CONTOUR —__ ® __ �. CERTIFIED PLOT PLAN
< -FWI-SNED SPOT ELEVATION ;.
RiNk9NED CONTOUR 0 ! y D a �' r' -
5%�];,..
The location of any existing undergrouewerage, IN
„ wells`,. or other utilities shown on this plan is approx-
s , mate only as determined from records and/or verbal
information. The contractor is responsible for the
' verification of the existing locations in the field. SCALES / "= d DATE ► / /Z/Fri"
r
1.DRf� ENGINEERING CO IN C.LIENT��_____�__
1, CERTIFY THAT THE PROPOSED
EGISTERE REGISTERED JOB NO. a� BUILDING SHOWN ON THIS PLAN
x , CIVIL LAN® _f,;� CONFORMS TO THE ZONING LAWS
DER RV DR. � �/�' � OF BARNSTABLE $ MAs
712 MAIN STREET CH. GYM
HYAIJNIB
, MA$S' SHEET I OF �_ D TE RE(3. LAND SURVEYOR
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ASSESSORS MAP:
--- TEST HOLE. L 0 G S
{� PARCEL:
SOIL EVALUATOR: fJ 'g �`�l I NOTES:
FLOOD ZONE: �cr7 A?PL WITNESS: 2 C*j ,
�. REFERENCE: �33� i' F✓ y7J
GATE: �V�i ' . installation shall comply with Title V and Town of Barnstable Board of
1- The installet o sal
wb4 _
t� � e
K��' ,D - 'PERCOLATION ON :RATE: •� ��'V►lW, 1 � ) P Y
� r - � Health Regulations.
�o (D 2 The installer shall v the location of utilities, sewer inverts and septic
3'
p
TH- I TH-2 components prior to installation.
1 A10 3) All septic piping to be 4 inch Sch 40 PVC at 1/8"per foot.
�f•rJ . '1 ; � i -� �w 4) Existing leach pits to be pumped and backfilled per Title V abandonment
pro cedures.
� � �y 5) This plan is not to-be utilized for property line determination nor any other
purpose other than the proposed system installation.
LOCATION MAP O. v ). 5 � �0 6) All septic components must meet Title V specifications.
7) Parking shall not be constructed over H10 septic components.
8) The property is bounded by property corners and property lines as depicted.
1C � 9) The property owner shall review design considerations to approve of total number
of bedrooms to be considered for design. Receipt of payment for the plan and
installation based on the plan shall be deemed approval of the number of
6
bedrooms.
�'f i
AS � J'1 10)Existing tank to be utilized if the tank is a minimum of 1000 gallons. Size is to be
verified at time of installation. If less than 1000 gallons a 1500 gallon tank is to
be installed.
SEPTIC SYSTEM DESIGN
oil
1
FLOW ESTIMATE
1 1 D �J3U GAL/DAY
BEDROOMS AT GAL/DAY/BEDROOM .
°
V SEPTIC TANK -
ti�
GAL/DAY x 2 DAYS - GAL
o �\ d USE IOD GALLON SEPTIC TANK
_- - ----
/ SOIL ABSORPTION SYSTEM
I DE AREA: Z1C 3 + ?-�-! X 7L, ►
l
BOTTOM AREA: 13 YC Z Ot�1 Z
� �i�i✓' � - _3 0
SEPTIC SYSTEM SECTION
oil
/�f ,3 / li :. _ key -
� • w,� �, � 3�,,.�� 1��_',71•�t,Y' �t /j1Dt��. 3b ►��X,
1000 GAL CJ7 D-BO d ''.. �) 1---�- 6 •, i �z3J
'� d!L � -
'` 1� SEPT I C TANK iti tU►l a'3 -. , , ,' T _A&
r
tit^ON
SITE AND SEWAGE PLAN
LOCATION : AIN �' A�m7rr (J�
PREPARE
D FOR : N 6U46V06Da_J
T
SCALE:
DAVI D B . MASON 125 DATE: 7 03
0
DBC ENVIRONMENTAL DESIGNS
j
EAST SANDWICH . MA
DATE HEALTH AGENT ( S 0 8 ) $3 3- Z 17 7