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0296 SCUDDER AVENUE - Health
296zScudder lAvenue Hyannis A = 288 - 226 a I r 4 0 IkL ii Commonwealth of Massachusetts °?g8r aaty Title 5 Official Inspection Form lo o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 296 Scudder Ave. ' V Property Address Richard Mumford Owner Owner's Nam information is required for every Hyannis Ma. 02601 6-8-21 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information So 1,54 o a- � on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path Company r� Company Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes jkk OF 2. ❑ Conditionally Passes ,�,z�:•• 'sq°yam, MICHAEL .Ny 3. ❑ Needs Further Evaluation by the Local Approving.Authority a c SEARS *; No.SI14430 :� . 4. ❑ Fails "=,'r�CWFRTtF '�`• lo`���. 9sci 6-8-21 Inspector's Signa>e Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 296 Scudder Ave. u� Property Address Richard Mumford Owner Owner's Name information is required for every Hyannis Ma. 02601 6-8-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: System is in working order 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form II; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 296 Scudder Ave. V Property Address Richard Mumford Owner Owner's Name information is Hyannis Ma. 02601 6-8-21 required for every y page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) P rY 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ 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 rep►aced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 3 of 18 I c Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 296 Scudder Ave. Property Address Richard Mumford Owner Owner's Name information is required for every Hyannis Ma'. 02601 6-8-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: c , 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 296 Scudder Ave. Property Address Richard Mumford Owner Owner's Name information is required for every Hyannis Ma. 02601 6-8-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 cf 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 296 Scudder Ave. Property Address Richard Mumford Owner Owner's Name information is required for every Hyannis Ma. 02601 6-8-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 296 Scudder Ave. Property Address Richard Mumford Owner Owner's Name information is Hyannis Ma. 02601 6-8-21 required for every i page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2019- 42636 gal2020- 39644 gal Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 i Commonwealth of Massachusetts 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 296 Scudder Ave. Property Address Richard Mumford Owner Owner's Name information is required for every Hyannis Ma. 02601 6-8-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 4 r Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f; 296 Scudder Ave. V� Property Address Richard Mumford Owner Owner's Name information is required for every Hyannis Ma. 02601 6-8-21 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 10-31-14 #2014-260 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 20" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet of joints venting, evidence of leakage, etc.): Comments (on condition � g, g ) t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 296 Scudder Ave. V� Property Address Richard Mumford Owner Owner's Name information is required for every Hyannis Ma. 02601 6-8-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 10"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal If tank is metal, list age: years � Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12 Distance from bottom of scum to bottom of outlet tee or baffle 17 How were dimensions determined? Sludge judge, tape, plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with inlet tee and outlet tees in place, cover 10" below grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 296 Scudder Ave. Property Address Richard Mumford Owner Owner's Name information is Hyannis Ma. 02601 6-8-21 required for every y page. City/Town State Zip Code Date of Inspection D. System Information 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 296 Scudder Ave. Property Address Richard Mumford Owner Owner's Name information is required for every Hyannis Ma. 02601 6-8-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16x16 with 2 outlet pipes, cover at 4" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 296 Scudder Ave. V Property Address Richard Mumford Owner Owner's Name information is required for every Hyannis Ma. 02601 6-8-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ,, Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 296 Scudder Ave. Property Address Richard Mumford Owner Owner's Name information is required for every Hyannis Ma. 02601 6-8-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 2- 500 gal drywells with stone, chambers are clean and dry with no sign of failure 12. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 296 Scudder Ave. u Property Address Richard Mumford Owner Owner's Name information is required for every Hyannis Ma. 02601 6-8-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts -, Title 5 Official Inspection Form �1; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 296 Scudder Ave. Property Address Richard Mumford _ Owner Owner's Name _ information is Hyannis Ma. 02601 6-8-21 required for every y -- — — ---- -- - --- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Y? 4n C t . 3u I 3� I 0 t �3 OF AA44,9. ' MICHAEL '.Gm- o; SEARS * No.SI14430 c T t FP�G`p```�. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 296 Scudder Ave. Property Address Richard Mumford Owner Owner's Name information is required for every Hyannis Ma. 02601 6-8-21 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water z ® Check cellar ® Shallow wells Estimated depth to high ground water: 144" 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: 7-11-14 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: No ground water per plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 296 Scudder Ave. Property Address Richard Mumford Owner Owner's Name information is Hyannis Ma. 02601 6-8-21 required for every y — page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 6, Nv t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 MORTGAGE INSPECTION PLAN s (THIS PLAN WAS NOT CREATED FROM AN INSTRUMENT SURVEY AND IS FOR MORTGAGE PURPOSES ONLY, 9G G MACDOUGALL SURVEY WILL NOT ASSUME LIABILITY FOR ANY OTHER USE). �G Dc rn- 0D o O G 7D LOT 8 z v SOT 6 c,• G OD Cam/ LO � O ys1} -#296: GPR j / LO t 7 �% 02 61 N O VS PARCEL ID: � _ PARCEL ID: 288/39 5�� 1 PARCEL2 8/204 07i O 288/38 PARCEL ID: 288/37 I CERTIFY THAT THIS MORTGAGE INSPECTION PLAN WAS PREPARED IN ACCORDANCE WITH 250 CMR SECTION 6.05 OF THE MASSACHUSETTS RULES& REGULATIONS FOR THE PRACTICE OF LAND SURVEYING. THE BUILDING SHOWN IS NOT AFFECTED BY A SPECIAL FLOOD HAZARD AREA AND DOES _CONFORM TO THE LOCAL ZONING BY-LAWS IN EFFECT AT THE 11ME OF CONSTRUCTION WITH RESPECT TO SETBACK REQUIREMENTS OR IS EXEMPT FROM VIOLA ON ENFORCEAa(T CTION UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 40A SECTION 7. REFERENCED DEED SUBJECT TO AND WITH THE BENEFIT OF ALL RIGH AY, ENTS;RESERVATIONS AND RESTRICTIONS OF RECORD, ff ANY THERE BE AND INSOFAR AS THE SAME ARE OF LEGAL FORCE AND EFFECT. i --.1�Es5ac)NAL LARD SURVEYOR. TOWN: BARNSTABLE (HYANNISPORT)���` �Ate, � ,• APPLICANTS: MAMFORD & JANINE RICHARDSON DATE: 07/02/14 CERTIFY TO: PETER L O'KEEFFE SCALE: 1"=80' —= of 91 TITLE REF: CTF 168937 asSg PLAN REF: 36483—D sH.3 MacDougall Surveying EDWARD cis FLOOD ZONE: "C" & Associates COMMUNITY PANEL P.O. Box 2428 ' STONE � 250001-0008—D Mashpee, Ma. 02649 DATED: 07/02/92 �. a.28 � CURRENT ZONING: A RB ph. (508)419-1086 4 " ©AFC b I fax. (508)419-1087 I ' , 5 F email: macdougallsurvey 41, L�'4° JOB# 11060 C�Dcomcast.net 6/7/2021 ShowAsbuilt(1700x2200) TOWN OF BARNSTABLE LOCATION CU SEWAGE#p?Q1(/-- tt�c7 VILLAGE ASSESSOR'S MAP /&PARCEIZZr AK 7"' INSTALLER'S NAME&PHONE NO.(fQJ'r(/(;L SEPTIC TANK CAPACITY/ Qll�rit� LEACHING FACILITY:(type)Z. :40o e7e/ NO.OF BED�OQM•S,3 OWNER PERMIT DATE: COMPLIANCE DATE: 10-131bIll 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 44C ej t 3° ' o . t�3 https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=288226&sq=3 1/1 TOWN OF BARNSTABLE LOCATION@;F 9C C U 9)Xt , SEWAGE#o'701(1y Z90 'VILLAGE ASSESSOR'S MAP&PARCE INSTALLER'S NAME&PHONE NO.� C t ,•�� f _ 2� 02� { SEPTIC TANK CAPACITY LEACHING FACILITY:(type) p ize)r, 3C /Z NO.OF BEDROOMS J OWNER 'G F PERMIT DATE: — ®/ 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 ��c K s��ec.vto c3� ® o w o_ TOWN OF BARN STABLE `f � y 4 �� � �LOCATION 26 Sc� Q� � SEWAGE # ' ` sVILLAGE ��/,%g ��� ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /000 4/p (size) NO.OF BEDROOMS RUM SER OR OWNER 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 144 .� . „�-- � � W��� . �- � � � . *mow � r ,� � �. � � �V � 1� < � � �i�. " ION P e [ WAGE PERIITIT NQ. �IILLACE IN TA ER'S A EI/ i ADDRESS 1 l c�� 49 5-7 R U I L D E R OR OWNER , Lj DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED r f G /SAI e' r � No,, _l P� .� y Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in compu er: PUBLIC HEALTH DIVISION - TOWN OF,BARNSTABLE, MASSACHUSETTS Yes Yitation for isosaY fps ern Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ❑Complete System � ndividuaI Components Locatio Address r of N . =evi e,Address,and Tel No. C4Pe Assesso ap/ParceI c• j Installer's�_N�ames� d Tel.No. Deis Na dse an Type of Building: C� Dwelling No.of Bedrooms 0 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building C�k&T (L- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.re ired) gpd Design flow provideda!99. gpd Plan Date Number of sheets Revision D to Title ` 6k-c-1X�> Size of Septic Tank `� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when app icable) ►` \� r Date last inspected: Agreement: The undersigned agrees to ensure the co s ction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of E iro ental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo H h. ( o Signed Date O Application Approved by Date 5'1 Application Disapproved by Date for the following reasons Permit No. _ 0 G 1"1 — 6d Date Issued No.� AM TIP Fee THE COMKAO14�EALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Misposal 6pstem Construction Vermit Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ❑Complete System ; ndividual Components Location ress�NY/. ^ Ow e s Name,Address,and Tel.No. Assesso ap/Parcel A, A0QAq(njo�)� J4 At,4' A 1�9 Installer's Name,Address,and Tel.No. D' i`t er's N d s,an Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other fixtures s ,---Design Flow(min.retired) gpd Design flow provided gpd Ply Date w n,LIF Number of sheets Revision D to Title ��� Size of Septic Tank , Type of S.A.S. \ Description of Soil 4'T%,, 'Nature of Repairs or Alterati�Answerpplicable) U \ w ��J I 0 Date last inspected: Agreement: r The undersigned agrees to eAthestruction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Titlro\ental Code and not to place the system in operation until a Certificate of Compliance has been issued by this BSigned Date Application Approved by Date Application Disapproved by Date l for.the following reasons Permit No. r? G Go Date Issued f -------------------------------------------------------------------------------- ------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( )' Repaired( ) Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.an/L{-#2b0 dated - q Installer kA Designer #bedrooms Approved de=' n flow / gpd The issuance of this permits all-not a Toned as a guarantee that the syste wfu'1 cfonnnasdesigned.Date Inspector / // Ij .- ----------------------------- -- `--------------------------------------------------------V/------�w- -----�---- - No. D O/LI — 0(00 Fee 1t� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Vermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( Abandon( ) System located at 7 q �j� A and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. r n Date 5( _� - �L Approved by ,VV NY4 I Town of Barnstable FI"E'O�+tio� Regulatory Services Richard V. Scali, Interim Director BAMSTABLE, 9�A M� �0� Public Health Division 'Fo ►�° Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: �� 0) Sewage Permit# � / �;��QAssessor's Map\Parcel Designer: ��z Installer: Address: l�l Address: 1 On :p 1 L/ o was issued a permit to install a date (installer) septic system atGr based on a design drawn by (address) "1 dated Tkh/ (designer) 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 ify that the system referenced above was constructed ' nce with the terms p oval letters (if applicable) \A OF 1qS DAVID y, B. G Z(rnsa re) rtilASOt� =+)E it"T'Signature) ` (Affix Desib ' p 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. Q:\Septic\Designer Certification Form Rev 844-13.doc Y7 5 Town of Barnstable P# / I Department of Regulatory Services f ' . BAMsTpB: Public Health Division Date / a� te39• �� 200 Main Street,Hy is MA 02601 /17 M /00 Date Scheduled p _ Tune Fee Pd. ---- 0 j © v So' uit 'y{►'�l►�ity/A�s)sessment for S isJ Performed By: � �`` witnessed By L" J ? LOCATION&GENERAL INFORMATION Location Address 6'�a/ l_/U PF'> /> Y Owner's Name Mi41 S o p fO r✓�•+ F✓.I�Y/'rjl�lyJ., t/ Address ^—� 1,�p�.p�c.J1(�"gI Assessor'sMap/Parcel: Z �Z"Z� Engineer's Name ✓• 3'_` ` NEW CONSTRUCTION REPAIR TeleP hone#IS06 Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line It Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) C 2 C W m Parent material(geologic) Depth to Bedrock ' W r� Depth to Groundwater: Standing Water in Hole: Weeping from Pi[Face M Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Date Time Observation Hole# I Time at 9" v Depth of Perc Time at 6" Start Pre-soak Time @ Time(9"-V) End Pre-soak Rate MinAnch .N�r r ,q Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- C/ I ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC f DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil er Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel YNW DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) 0 tqductZ \0 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION H_ OLE LOG Hole# Depth from - Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) Flood Insurance Rate Mai): / Above 500 year flood boundary No //Yes V Within 500 year boundary No V Yes Within 100 year flood boundary No Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pery o material exist in all areas observed throughout the area proposed for the soil absorption system? .� M`,, If not,what is the depth of aturally occurring pervious material} Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Envir nmental Protection and that the above analysis was performed y me consistent with the required training, pe e d experience described in 310 CMR 15.017 ` Signa Date? L°l Q:\SEPTIC\PERCFORM.DOC No......9%, mU y6 Fxs....... '�........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................OF.............................--......---------.......................................... App iration for RaposFal Works Tonstrnrtinn Firmit h - Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal r Syst at* Ze 2 � � Locations-vAddr ss A/�.......1�._!` �d.�1111� -1 •4F--__Clr ���`.� �Ad ` .C � •... caner d _- r /� es),� ►-a Insta er Address ff d Type of DwellindingNo. of Bedrooms_________________' Size Lot____ �._1Q-�._..Sq. feet U g v __________________________Expansion Attic ( ) rage Grinder ( j) Other—Type of Building ____________________________ No. of persons............................ Showers — Cafeteria aOther fixt es . •'-"--"'•-'-•-----•-"""'-•"•---_..."-----------------------------------------••••--•-""-""''(/) ------------------- d W Design Flow......... _____________________gallons per person per day. Total daily flow.___.____ __ •••-•-•.._..___..gallons. W Septic Tank—Liquid'capacity./AA .gallons Length..................Width_;_____________ Diameter________________ Depth................ x Disposal Trench—4 o.-----------'_______ Width____________________ Total Length.................. Total leaching area....................sq. ft. Seepage Pit No.__ __.__.______ Diameter----,l�__ Depth below inlet___.__________ Total leaching area____ ...sq. ft. Z Other Distribution box ( ) Dosing tank `~ Percolation Test Results Performed by....... . -'- ---------------------------------------------- Date........................................ Test Pit No. 1................minutes per inch Depth,;of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth,of Test Pit.................... Depth to ground water........................ 0 Description of Soil".,........................................................................................................................................................................ , x W --------------------------- =-=---------------•••---•-----•------------------------'--•---------------------- .................................................................................... U Nature of Repairs or,, —Answer when applicable_______________________________________________________________________________________________ Agreement: „ u The undersigned agrees to install the aforedescrib`ed`'•individual Sewage Disposal System in accordance with the provisions of TITi= 5 of the State Sanitary Code—The undersigned further agrees=not to place the system in operatio u it a C fica of Compliare has been is ed b boar of health Signed-" ' ._.. _ ..-^---•- -------- ------------------ '----- .-- ...... ate XAp1 anon Ap o d BY----- --------•---- - ..-•--- ..----=- •- --------------•----•-- -•------. .... 17�te Application Disapproved f r the following reasons:.............................................................................................................. --......-'-"'--"•.._.....-"""'-'-•"-•--"-"-"-'•-'•._...___"""--"•................"-...._......"""•-'--..."'---'-'-'----""-•---'-'----•---•--'--•---•--•----'----- " "- '-- '--- Date PermitNo..............r4........................................ Issued..........................-............................ Date y, p � No.....92..;K-n is y6 FES..... ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4 ...........................................OF....................................... Appliraiila t4pr Disposal Works Tontrnrtion rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy�stt'em at:// (� /�`� / �/ �y /� /� fr i l k /1 ..—A`� L✓ PN... P lam/ 1 .1 ��'v �G/! - - Location-Add ess Lot o ....................................... •- Owner .................... -•----••-•------------.....--•-•-..............-•-----••-------- .......... Installer Address f Type of Building Size Lot_ TT..��......Sq. feet .......... U Dwelling—No. of Bedrooms...... ............................Expansion Attic ( ) Gafbage Grinder pal Other—Type of Building ____________________________ No. of persons............_......_-------- Showers V — Cafeteria ) Pa Other fi es ............................ W Design Flow................... ......................gallons per person per day. Total daily`flow........ ..........................gallons. (:4 Septic Tank—Liquid capacitylJl�..gallons Length................ Width................ Diameter---------------- Depth................ xDisposal Trench—No..................... Width.............__.__-- Total Length............ ..f--- Total leaching area....................sq. ft. -.._.-_-_ ,1JV... De th below inlet.............. Total leaching area.._.. ....s ft. � Seepage Pit No.. _._ Diameter__. __. p g q. Z Other Distribution box ( ) Dosing tank ) ~' Percolation Test Results Performed by............... ... .1................................................. Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ C4 -•--------------------------•-••---•------------........-----------....--•------.....••-----•---•--......_.....-•-•--...---•--------•-----•....-------•...... 0 Description of Soil........................................................•----------------....-------------------------------------•-•----------------------------------------------•---. x V -•---•--------------••-------•------...._...-•-•------------------•-------•--•---•---------------•-------------••---•-------•--------•-•--•----------.....-•-------•--••--•---•--------.....------------ W ------------- V Nature of Repairs or Alterations—Answer when applicable___________________________________________...........__............._....�i..._..._............. ----------------------------------------------------------------------------------------------•....-••---...-----------•-••-------•---•••-•----•-•---••••---•----•-•---•-•----•--•--••-------.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance,with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system,i in operation until a Certificate of Compliance has been is ued by boa of healt . �/ i �� Signed L + 1 ---------• .. ---- e Application Approved By..................... Y l�...............•.---_.. l�. Application Disapproved for the following reasons-.....................:'......................................................................................... -•--------•---------•---------------------•-•---.....--•---------........••--•---•---.....---------..........._.......--•••••--•---••----••-----•------••-•-----••-•--•••--•••-----------•---•......-•--- Date PermitNo.......................................................- Issued....................................................... Date THE COMMONWEALTH OF',MASSACHUSETTS BOARD OF HEALTH ......................................OF..................................................................................... Trr#ifirtttr of foot li�tnrr THIS IS TO CERTIFY, That the Indivi ua Sewage Disposal System constructed ( ) or Repaired ( ) by------------------------------------------------------------------------------ ns all; at.............................] 4 ;0 !::� has been installed in accordance with the provisions of TIT 5 of The,State Sanitary Code as described in the application for Disposal Works Construction Permit \To.___...._.��'�✓1� •-___.._•. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. DATE....................................... �- Inspector.. ' -------------------•-..---- THE COMMONWEALTH OF MASSACHUSETTS G BOARD OF HEALTH No....(J %�G�� .............................1............OF..........................................................................................�............ FEE...s....0............. Disposal Works T nsir ion rrmi# Permissionis herby granted.................................. --• .---... • ............................................................................. to Construct ( aep it ( ) an dividual ew ge Disposal System --�/ atNo........ ..... ......... . --------------•-----•-••... Street as shown on the application for Disposal Works Construction Permit ..........------- Dated.......................................... Board of Health DATE................................................................................ FORM 1255 A. M.-SUL,KIN, INC., BOSTON t " 1 r Permit' t.uriber: Date: tg� n Completed by. ; Sj�x54 HIGH GROUND-WA7.ER LEVEL COM.PUTAT I OPJ � Site Location: Lot No. f Owner: Address: Contrz;ctor: Address: Notes: u STEP 1 Measure depth to water tableto nearest 1/10 ft . . . . . . . . . . . . . . . . . . . . . . date Y [STEP 2 Using Water-Level Range Zone and In Well PSap locate a �3l ({ - site and determine: - - - A) Appropriate index well . . . . . . . : PF. x B) Water-level range zone . . . . . . . 7� STEP 3 Using 'monthly report"Cur rent Water Resources Conditions" J.,64 2 deter rnine current depth to water level for index well - mo y r ° STEP '4 Using Table of Water-l ever Ad j us t.rnent s for index wel1 eat; STEP 2AT, current di:pth to ' water level for index well (STEP. 3) , and water-level zone (STEP 2R) determine f water-level adjustment 2` g 7 : t S7EP 5 Estimate depth. to high water by subtracting the water Level adjustment .(STEP 4) n ` from measured . depth to water` : level at site (STEP 1 ) . . . ... . . . . . .. . . .. . . . . t: s' Y r �/tea i.. CO�I,ViGNWtALTH Or INIA,SSACHUSET EXECUTIVE OFFICE OF ENVIRONM TAL AF49 DEPARTMENT OF ENVIRONMENT PPRC �TION ONE WINTER STREET, BOSTON MA 02108 (61 r292-0500 5 1999 `B lOINN OF BARNS TRUDY CO.XE Secretary A.RGEO ?.:UL CELLUCCI DAVID B. STRUMS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 296; J"., Name of Owner /9 n.7.,,'s rlovT Address of Owner: 7 R Date of Inspection: �,6- 5�0/ Name of Inspector: (Please Print) I am a DEP approved system ins to Section 15.340 of Title 5 (310 CMR 15.000) company Name: 70 — .1K ; Ma.T+ng Address: /$2 ax'g :-r�..7 S�, Telephone Number: sV`a- 9`7 P•91-25- CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _✓Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: v r Date: The System Inspector hall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS 4 9 �1d _ �E �0 NVEQ M i A Y 5 1999 ftWOFs �B -f=vi sed 9/2/98 Pagel of11 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: :2��v Su+/�r[d!r vQ 5�nri�o✓/� �A. Owner: Qr 6,-- PG$/c,?I'/p.. / Date of Inspection: .I / y-.2 9--`9 9 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: T I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDMONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. backu or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) Sewage P 9 or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed s� ' * t revised 9/2/98 ;� � Page 2of11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: S�.rx�lr fi�v{ /y�Nr�H1110 lye, Owner: lot. �jrlC�vv y Af k1{-i y. Date of Inspection: y-2 8- '9 ' 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for 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. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 1 . _ r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Z C1�S $cwddir Ave /7yGHHi S�or�j ,,/u Owner: p- 6'5rv -y fGskrr,�,� Date of Inspection: y-z 8-99 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less thari 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes".or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST � Property Address: 2 SCE Owner: Q,. 6p:/J,Vt, D Date of Inspection: r r�' S aria H y- z 5-99 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Y _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for-at least two weeks and-the system has been•receivingmwmal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. • _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or.industrial waste flow. The site was inspected for signs of breakout. I/ All system components, G/axctudics7the Soil Absorption System, have been located on the site. V _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. , The size and location of the Soil Absorption System on the site has been determined based on: t-r WIZ ""^w r '' _ Existing information. For example, Plan at B.O.H. h,Op�uvr Cs Bo/z Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5of11 t.. I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2 96 Scr r'1 ,. '9" /Jaryy i s/Jvr* /Yti, Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 1 10 -g.p.d./bedroom. Number of bedrooms(design):_ Number of bedrooms(actual): 3 Total DESIGN flow 3?o Number of current residents: / Garbage grinder(yes or no):�1/m h/ Laundry(separate system) (yes or no):A If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):-1•/D Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no): /(/a Last date of occupancy: o GNpiA1 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ • Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: A=,Oze a-;?`/—�� System pumped as pa of inspection: (yes or no) / 1 If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM I/ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other 20 /Hs ts,ry APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no)_ 10 revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION(continued) Property Address: ,?4(, fi/�uhh/S Owner: Or.Greo /0 sk,,j Date of Inspection: / BUILDING SEWER: (Locate on site plan) Depth below grade: 5o�r Material of construction:_cast iron._40 PVC other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: ' Material of construction: concret metal_Fiberglass _Polyethylene_other(explain) — p If tank is metal,list age_ .Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: /''�z" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Y '�1" Distance from top of scum to top of outlet tee or baffle: 9 Distance from bottom of scum to bottom of outlet tee or baffle: /�"�� How dimensions were determined: N/p�Syy�Y rvc� o- ru� Comments: (recommendation for pumping, condition of inlet andL outlet tees or baffles, depth of liquid level inrelation to outlet invert, structural integrity, evidence of leakage, etc.) 3PQ G r+/\ �<tv/-i �:�+ Dfa /r y GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ��L�S��/�Y"STE M INFORMATION(continued) Property Address: !I9(j SCK��1✓ �!�{ ikhH�}lJoY/� Alam, Owner: nn Date of Inspection: / y-28-9� TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) �r Depth of liquid level above outlet invert: Comments: (note if level and distribution^is equal evidenceof solids carryovef, evidence of leakage into or out of box, etc.) _ O!'v��lr by Gv f✓V y "-A 5 Gf'ueh,0'1 �- I^� wi�� A�P![l cot/ PUMP CHAMBER:_ (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.) revised 9/2/98 page sorn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'X SYSTEM INFORMATION(contirxred) Property Address: C1.�d yr �v� �y4�7kil Owner: ,Q/ �svEc'cr sr P_ Date of Inspection: // SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, if possible: excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers,number:_ leaching galleries,number:_ leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of pond)n , dam soil, condition of v getation, etc.) = O t * Corr cr Q �, y.r���. y' .� "�.,Jet C CESSPOOLS:_ (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 (cesspool must be pumped as part of inspection) 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.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION (conttimed) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wills within 100' (Locate where public water supply comes into house) 0 v i7 i revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 96 5 c ti '44v �v? /7`JG,v7h,S�o`t Owner: <c� Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater N,45Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record L-' Observed Site (Abutting property, observation hole, basement sump etc.) //Determined from local conditions JZ Checked with local Board of health Checked FEMA Maps Checked pumping records ✓Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Ycwn /all Neu/1-4 Vew' 7S revised 9/2/98 Page 11of1I NOTE /Ir Ei TN�.�' TNT SFPT/C 7AA' p F 2® GT MIJi/. ♦--.ACAIIIVG 9>17 A14'E /^SORE 'Y'NA.IV /2°4ELOJv Si'PYL" PIPS . .� '' 3loItya7 7"O Cad 7'" /6'C�1Y Co a% 'yt: Sh✓-� L DE U S E.[7 CO�El�s'S //V lCoRl�/E.;lVA y CO CL A-A V SAI►!® �7A 0 e� � O �� or � r /�' %�iMX JPJ ®f s7: " ® e a : e • o ® e a ® e a e 6YpeS�6PD S�JIY� BOX p f p ® f Y e of a�♦ a f2N ♦ e o e e DEPTH ' e o • ® o )VASWEP STD11E ( �? x / .0 = 1/33 a ee w s . ® ea pro j, PREC✓ 5r"I.Eft;p 4GE" ------ a r'® e 490I Cl�_-'Y t e® ® ® ® o ® ® ® e e m m P/T OR ML11V. t � Je a G'.o � /IVy,ex*r AT DVld.DSNG !! Fr3 hv4E7 "PITIC 7.4,VK IoSB FT r� FZ D/Am. c(5�� /L�47JDA� DU7L ET SEP-71C 7A/ViEC _par C-LE7l,'96.3 !A! 'DdS�R/$IOTBO.�! BOX /o S_ GRovND 72.R Ts.ZE /3'1°4J� (�i�✓U tx��Z- 1"4.5T krACRING ®iT t o S.o cr SEAVASR AVISAONSA 4 SYST� 'rA I-ATfO/i/ • OdrVEN.S'1.01A/ A DffSl N CX 7ENIA- /d __Irr• NC/l$9SEFs' OF&EDRO®� . 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" %.- .Ap. . ,, i, - .V i � " ).:.Xt I I*-;'�,I,,-,,"'11-I- , - I -I-- -I I - I- I - - �- I'll- I - I - - , , - ,-,_`� _ N ." �, ,. R 1?1�11 i"VAR111 L 4 ��' I ..%.,% . %I I 4,•i'104i.- vj . , . .�1,4k "; "4 'C�771, , -�l m .i,, - _ ,V , - , ". ,;,P�,- ". -. . .. .�,,:.---, . - 1 L - ."widdl.,17"I. " �,4-: .."t , IV �! . I I - r I I 1 ASSESSORS MAP : - `z8 ._--_--__ TEST HOLE LOGS r I 1) "1'he installation shall conji.,, with Title V anal •fuwu uf���'��,�,13oard ol. PARCEL: .Z .... alth Itegulations. ---~� - SOIL EVALUATOR: III l Ile ocation of utilities sewer inverts and septic FLOOD ZONE: �/O`f ,�,�O�G� 2) 'I'lle installer shill verify the I , _ WITNESS : "1 b REFERENCE: ! i components prior to installation and selling base elevations. _ �! G42'-"- l� DATE�� �� 3 All gravityseptic piping to be 4 inch Sch 4li PVC at U$" per lioot.'I'he first PERCOLATION A TE: .G2,14141 1 two leet'out of the d-box to the leaching shall be level. l � /+ � -��� �� �/� ( !, q) This plan is not to be utilized for property line determination nor any other 1013 /9� TH- ( TH-2 purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over I I 10 septic components. 7) The property is bounded by property corners and property lines. r, LD b 8) The property owner shall review design considerations to approve of total !by i Ib d26 gi O design flow and number of bedrooms to be considered for'design. Receipt LOC `' ,� of payment for the plan and installation based on the plan shall be deemed AT I OI! MAP ?emu �-8 p Y (}� 12 1 approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material 1 Title V abandonment procedures. Those within (lie proposed SAS shall s per : be removed along with contaminated soil and replaced'with clean sand per 'Citle V specs. 5 09 10)System components to be 10 feet front water line. Sewer lines crossing (lie lo water line shall be sleeved with 4 inch SCI 140 PVC with ends grouted if pp proposed g i the water service t applicable. Cite ro osed SAS is being installed below line. The line is to be sleeved as aforementioned and maintained in place. cinder exists it is to be removed and is (lie responsibility of the v, e P If a garbage _ 11) g g g SEPT I �C SYSTEM DES I GN s� M owner to ensure such. 12)The installer is to take caution in excavation around the gas line if stich -G FLOW ESTIMATE 1 exists. 2 13)The installer shall verify the location,quantity and elevation of the sewer BEDROOMS AT GAL/DAY/BEDROOM -33� GAL/DAY lines exiting the dwelling`prior to the installation. 14)This plan is representative only that a system can fit on a property meeting Title V requirements. SEPTIC TANK 9 o 1 I -7?>.... Z GAL/DAY x 2 DA S - �D GAL ------______ l ��4151 1 USE IDDD GALLON ^SEPTIC TANKf,44') sod �IZ AB S lT_ EhT�-_ 1 uAViD-- c SIDE AREA: Zra �Z- ,� ! ( s - X t I2 � ,7 o 0 4 0 4 = BOTTOM AREA: 26 x �1 �� . . S EPT C' SYSTEM SECTION 61 0m11(('� 4L , - 1 ID I�� at?Ficrc IC �14X, o9 r;.ell- aa _.. - �I a-_s,F 9 l GAL I �(, y ►�(E - I�lT l�� a '� l. '_. U?kf% Q STD SEPT I TANK �Uti V. 1�� SITE AND SEWAGE -) LAN -- !� 2j1i LOCATION . PREPARED FOR : Ly-DIOLd. Ch SCALE DAV I D 6 . MASON,R5 PATE: 2 � DBC ENVIRONMENTAL DESIGNS s EAST SANDWICH . MA W DATE ( HEALTH AGENT ( 508 ) 833- 2177 i