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HomeMy WebLinkAbout0554 SCUDDER AVENUE - Health r554'Scudder Averiuetr � Yr k287�015"� } V� C�n n V\ Dq i I a o � u I j v -j II, i f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System For-Not for VoluntaryAssessments ments •• 554 Scudder Ave (2 systems at property this is the mai Property Address n house see comments on pq 2) Boiardi - Owner information Owner's Name is required for ✓ every page. F onnis MA 02601 5/9/18 City/'TownState Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way". Please see completeness checklist at the end of the form. A. General Information �l � 1300 � 1: Inspector: Frank Nunes Ill Name of.inspector saa Company Name: Box 841 Company Address East Falmouth MA 02536 Ci ty/Town State 508.272.6433 Zip Code 13010 Telephone-Number License Number B. CWtification 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 8(310 CM 15.000).The system: ® Passes ❑ Conditionally Passes. El. ❑ Needs Further Evaluation'by the Local Approving Authority 5/9/18, . .. Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health orDEP)within 30 days of completing this inspection. If the system has a design flow 10,000 gpd or greater, the inspector and the system owner shall submit the.report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable,and-the approving authority: ****Thin 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, 6msAoc rev.;6/16; Title 5 Official Inspect on Form Subsurface Sevrage Disposal system-Page,l,ot iT Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage DisposalSystem Form.-Not for Voluntary Assessments 554 Scudder Ave 2 systems at: roe this is:the main house, see comments on ;2 Property Address Boiardi Owner information Owner's Name. is required for every page. Hyannis MA CitylTown 02601 5/9/1$ State Zi :Code - P Date of Inspection B. Certification (cont.) Inspection Summary: Check.A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.3.04 exist.Any failure.criteria not evaluated are indicated below. Comments: Per owner the leach pitisoh4he neighbor's property B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired:The system;upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no'or"not determined" (Y, N, ND)for the following statements. If"hot determinedi"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 orexfiltration ortank failure is imminent. System oar of Health. .ass inspection if the:existmgtank Bard is replaced with a complying septic tank as.approved by the Bo . "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)'< t5ins;doc rev,6176 Title S Official inspection Fonn:subsurface Se%iige Disposal System' Page 2',of'1Z; Commonwealth of Massachusetts Title 5 Official Inspection F - p Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Scudder Ave (2 systems at property this is the main house, see comments on p 2) Nroperty Address Boiardi Owner information Owners Name is required for every page.. Hyannis MA 02601 5/9/1$ P Cityrrown State' Zip Code ` Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the-distribution box due to broken or obstructed pipes)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): El distribution box is leveled of replaced ❑ Y ❑ N ❑ ND(Explain below): Ej 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,,safetyorthe 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 ❑ Gesspooi'or privy Is within 50 feet of a surface water ❑. Cesspool or privy Is within 50-feet of a bordering vegetated wetlarid or.a salt marsh` tsini.doc•rev.6/16 - Tide s offiaai Ins pedion Form,Subs. C8$swage Disposal System'•Page-3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fry ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ssments * 554 Scudder.Ave 2 s stems at roe this is the main house, see comments on 2 Property Address Boiardi Owner information Owner's Name is required for every page:. _Hyannis CltylT own MA 02601 5/9/18 State Zip Code Date of inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 1 100 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. [Q The system has a septic tan-k Ond 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 Y , p med at a DEP certified laboratory, for fecal coliform bacteria indicates absent,and the presence of ammonia nitrogen and nitrate nitrogen is equal. to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to.All Systems: You must indicate"Yes"or"No"to each of the following for all"inspections: Yes No Backup of sewage into facility orsystein component due to overloaded or clogged SAS or cesspool El 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 0 `Liquid depth in cesspool is less than 6`.bel6w invert or available volume is less than %day flow tins-doe rdly.6/16' ; TNe S;Offici9l Inspectitin Form:Subsurtace.sewage Disposal System Page'4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-`Not for Voluntary Assessments 554 Scudder Ave 2 systems at property this is the main house, see comments on pg.2) Property Address Boiardi Owner information Owner's Name .is required for every page. Hyannis MA 02601 5/9/18 Citylfown State Zip Code Date of Inspection. Certification (cont.) Yes No Ej Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numberof times pumped: ❑ Any portion of the SAS, cesspool or privy is.below high ground water elevation. Any portion of cesspool or privy is within100 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. El Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 Any portion of a cesspool orprivy.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 toor 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- ® 101000gpd. ® The system fails. I have determined that one or more ofthe above failure criteria exist as described in 310 CMR 1.5.303,'there-fore 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 afacility with a design flow of 1o,000 gpd to 15,000 gpd.' For large systems,you must indicate either"yes"or"no,,to each of the following, in additionto the questions in Section D. Yes No ❑ the system is within 400 feet of a surface drinking water supply F1 El the system is within 200 feet of a tributary to a surface drinking water supply 0 the system it 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 he 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 contactahe appropriate regional office;of the Department: - t5imAoc.•.rev.6116. Tiue 5 o6daHnspection Form:Subsu6aee Sewage Disposal System_=Page 5 of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 554 Scudder Ave (2 systems at property this is the main house see comments on p 2) Property Address Boiardi Owner information Owners:Name is required for every page. Hyannis MA_ . . 026b i 5/9/18 Cltyfrown 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 El 0 Were any of the system components pumped out in the,previous two weeks? ❑ 0 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? ® E] Were as built plans of the system obtained-and examined? (lf they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ 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? El 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: 0 ❑ 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: Numberof bedrooms(design) 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15:203(for example::110 gpd x#of;bedroom 440:s): _- - t5ins docr rev'.C116 TRW.S Official Inspi coon Form SubsurfaceSe"ge Disposal System-Page 6 oP;t7+ Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not forVolunta 'Asssees'sm" rY ents 554 Scudder Ave (2 systems at property this is the main house, see comments on p 2) Property Address Boiardi Owner information owner's Name - is required for everypage. Hyannis MA 02601 5/0/T8 Cityfrown State ZipCode Date of Inspection D. System Information Description: 3 bedroom permit 1981 Number of Current residents: p Does residence have a garbage grinder? Yes No Is laundry on a separate sewage system?(Include laundry system.inspection information in this report.) ❑ Yes Z No Laundry system inspected?' ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last'2 years usage.(god)) Detail: Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310;CMR 15.203): Gallons per day'(gpd) Basis:of design fl6w(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 'Watet meter readings, if;available: _ t5ms doe+rev 6/.16'. Tide 5 O(fiaal Ins PwAion Form:Subsurface`Sewage Disposal System:%Pagel of 17 Commonwealth of Massachusetts _ ki Title 5 Official Inspection Form o p Subsurface'Sewage Disposal System Form -Not for Voluntary Assessments 554 Scudder Ave (2 systems at property this is the main house, seecomments on'pg 2)Property Address Boiardi Owner information Owner's Name. is required for every page. Hyannis MA 02601 5/9I1$ City/Town State Zip Code Date of Inspection D. System Information (cont:) Last.date of'occupancy/use- Date Other(describe belowy General Information Pumping Records: Source of information: No recent pumping per owner ------------ Was system pumped as part of the inspection? Y. ❑ Yes ® No If yes, volume pumped- gallons How was,quantity pumped determined? Reason for pumping: T.ype;of System: ® Septic tank;`distribution box, soil absorption system El Single'.cesspool El Overflow cesspool ❑ Privy Shared systern (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 11A system by system operator.under contract 0 Tight tank.Attach a copy°of the DEP approval. Other(describe): t0ins.d.ocl>rev,Wi 6, Tille5OffidatInspection'Form:?Subsurface,SewageDisposaiSystemra.Pagei:8of.1T Commonwealth of Massachusetts _ Title 5 Official Inspection n Form. p Subsurface Sewage Disposal System,Form-Not t for Volu ntary Assessments 554 Scudder Ave (2 systems at property this is the main house,see comments on p 2) Property Address Boiardi Owner information Owner's Name is required-for every page. Hyannis MA 02601 5/9/18 Cityr town State ZipCode Date of.lnspection. D. System Information (cont.) Approximate age ofall components, date installed(if known)and source of information: 1*081 pet BOH record Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade' 12" feet Material of construction: ❑cast iron ID 40 PVC El other(explain): Distance from private water supply well or suction line: '1p. feet Comments(on condition.of joints; venting,evidence.of leakage, etc.): Septic Tank(locate on site:plan): Depth below'grade: 3" feet Material of construction: ®.concrete El metal ❑'fiberglass ❑`polyethylene ❑other(explain) H-10 tank If tank:is metal, list'age year Is:age confirmed by a Certificate of Compliance?(attach a copy of certificate)' ❑ Yes ❑ No Dimensions' 10002 Sludge.depth: 4" t5insldoc.•rev 6m tale 5 Official!ns pection Form:Subsurface Sewage Disposal e:9 System:•Pagof il' Coimmornwealth of Massachusetts Tithe 5 Official Ins ection Form m _ p Subsurface Sewage Disposaf System Form-Not for Voluntary Assessments Sye.- 554 Scudder Ave (2 s stems at property this itthe:main house see comments on pg 2)Property Address Boiardi Owner information .is required for Owners Name every page. Hyannis MA 02601 5%9/18 City/Town State ZipCode Date of Inspection D. System Information (cont.) Septic Tank(cone) Distance from top of sludge to bottom of outlet tee or'baffle '12 Scum thickness trace-l/2 Distance-from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee of baffle '2 How were dimensions determinetl? 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.): Pumping suggested every 3 years to prolong the life of the system Grease Trap (locate on site:plan): Depth below grade:_ feet Material of construction: concrete ❑ metal ❑fiber lass 9 ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee:or baffle. "Distance from bottom of scum to bottom of outlet tee,or-baffle Date of;last pumping: Date t5ins.doc•rev.:6116.. Title 5 Official Inspection Fonti:'Subsurface Sewage Disposal System-Pago,ip of 17 Commonwealth of Massachusetts Title 5 Official Inspection For 0 Subsurface Sewage Disposal System Form Not-for VoluntaAssm Assessments ents 554 Scudder Ave (2 systems at propeqy this is the main house, see comments on 2 Property Address Q ) Boiardi Owner information Owners Name is required for every page. Hyannis CRY/I own MA 02601 5/9/18 State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,. liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at:time of inspection) (locate on site plan):. Depth below grade' (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 a5ms:doc�rev.6/16 Ttle 5 Official Ins " ' pection Fonn:Subsurtace Sewage Disposal SystertY:�:Page 1:1 of[1T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 554 Scudder Ave (2 systems at property this is the main house, see comments on p 2) Property Address Boiardi Owner information Owners Name is required for every page. Hyannis MA. 02601 5/9I18 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be Opened) (locate on site plan) Depth of liquid level above.outlet invert Oil 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 1' below grade and in average condition for its age 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. $oil Absorption System(SAS) (locate on site plan, excavation not required).: If SAS not located;;explain why: i5insdocr rev;6116 Titles Offiaat Ins"pection Form:Sutisuiyface Sewage Disposal System.-,,Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 554 Scudder Ave (2 systems at property this is the main house, see comments on pq 2) Property Address 8oiardi Owner information Owner's Name " is required for every.page. Hyannis MA 02601 5%9/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: 1 El leaching chambers number. ❑ teaching galleries number: ❑ leaching trenches number, length;. El leaching fields number, dimensions: _ ❑ overflow cesspool number: El innovativelalternaf ve system Type/name of technology: Comments.(note condition of soil,signs of hydraulic failure, level of'ponding,damp soil,'condition of vegetation, etc.): Leach pit is 1' below grade; damp at this time; stain line Z below invert, no indication'of past hydraulic failure, probing indicates'2-T of stone surround 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 ground water:inflow ❑ Yes. ❑ No t5iris.doc reJ.6f16: y Tine S;Oihdal Inspection Form:Subsurface Sewage Disposal System-Pag'e 13,of'17 1 Commonwealth of Massachusetts Title 5 Official InS ection Form Subsurface Sewage Disposal System For-Not for Voluntary Assessments yve'e� 554 Scudder Ave ('2 systems at property this is the main housej see comments on p 2) Property Address Boiardi owner information Owners Name is required for every page. Hyannis MA 02601 5/9/18 CltylTown State Zip Code Date of Inspection D. System- Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation, etc.): Soils are compact and dry 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.): Min*ioc.-rev.6l1$. Tithe 5 Otfiaat I nspection Form:Siilisurfa'ce.Sewage Disposal Systa•Page 14of 17. i Commonwealth of Massachusetts �a Title 5 Official Inspection 'Form Subsurface Sewage Disposal System Form-Not for VoluntaryAsses s M ,•`'� 554 Scudder Ave (2 systems at property this is the main house see comments on pg 2 Prnr y Address Boiardi Owner information Owners Name is required for every page. Hyannis MA 02601' Cityfrown 5/9/18 State Zip Cute Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate Where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately 2 aaG 3 t5ms tloC-rev 6(16' _ - `Title 5 Official In .spediori Form:Su6sur &.sa ma©e Disposal System :Page:15_of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Scudder Ave (2 systems at property this is the main house,see comments on 2) Property Address Boiardi Owner information Owner's Name is required for every page. Hyannis . MA 02601 5/9/18 Citylrown State Zip Code Date of inspection D. System Information (c(int.) Site Exam El Check Slope ❑ Surface water. ❑ Check cellar ❑ Shallow_wells Estimated depth to high ground water: >12 feet Please indicate all methods used to:determinelhe high ground water elevation: Obtained from system design plans.on record If checked, date of design plan reviewed: Per 1981 compliance Date Observed site(abutting property/observation hole within 150`feet of SAS) ®, Checked with local Board of Health-explain_ 2003 inspection fe-p6rtneighbbring property n w at 18' 2005 inspection 16 estimate ❑ Checked with local excavators; iinstallers-(attach documentation) ® Accessed USGS database-.explain: TOPO mapping You must describe how.you established.the high ground water elevation: The site is 22' msl with nearby surface water at 5'msl Before;filing this Inspection Report,please.see Report Completeness Checklist on next page. t5ins:doc `rev.611B Idle S:OFfidai Inspection Form:Subsurface Sewage Disposal System•page 16 or 11 Commonwealth of Massachusetts Title 5 Official Ins ,ection For p m Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Scudder Ave (2 systems at propertythis is the main house, see comments on pq 2)Property Address Boiardi Owner information is required for Owners Name every page. Hyannis MA 02601 Cltylrown 5/9/18 State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, 8, C, D; or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed 0 System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc rev 6/]6' Ue 5 ofnaall- pection forir 'Subsurface Sewage'f)isposal System+.0age_1Tof 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Scudder Ave. (2 systems at this property this is the garage system) Property Address Boiardi Owner information Owner's Name / is required for ✓ every page. Hyannis MA 02601 5/9/18 City/Town State Zip Code Date.of Inspection Inspection results must be submitted on-this form. Inspection'forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information �Io 1. Inspector:. Frank.Nunes ill .Name of Inspector -saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town • State Zip Code. 508.272.6433 13010 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 ❑. Conditional) Passes Y El Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/9/18 Inspecto ignatur 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:inspectorand.the system owner shall submit the report to the appropriate regional office of ttie.bEP.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. iSns doc:•'rev'6)16. Title s Orfiaal lnspectfw Forrrr subs idace sewage Disposal System•page V6f i7 S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form--Not for Voluntary Assessments: 554 Scudder Ave. (2 systems at this property this is the garage system) Property Address Boiardi Owner information Owner's Name is required for every page. Hyannis MA 02601 5/9/18 CitylTown State Zip Code Date of Inspectio- n-B. Certification (cont.) Inspection Summary:Check A,B;C,D or E/a/ways'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: Permitted for a garage rec room. 13) 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 re 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 over20 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 com Board of Health. plying septic tank as approved by the *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) t5ina.doc•aev.6/16 Title 5 Official Ins on Form'Subsurtaoe.Sewage Disposal System+Page 2 of 17 Pam... Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not forVoluntary Assessments M >•`' 554 Scudder Ave. 12 systems at this property this is the garage system) Property Address Boiardi Owner information Owner's':Name is required for every page. Hyannis MA 02601 5/9/18. City/Town State Zip Code Date of Inspection B. Certification (cont.) El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)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),- .El obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled.or replaced 0 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: El 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: El 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 salt marsh t5ins.doc:•4v:6)1ii` Tdle 5 Official Inspection Form:Subsurface Sewa a Dis posal sposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System form-Not for Voluntary Assessments M ,•`'•y 554 Scudder Ave. (2 systems at this property.this is the garage system) Property Address Boiardi Owner information owner's Name is required for every page. Hyannis MA 02601 5/9/18 . Cltyrrown State Zip Code Date of inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS its 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 wel1.'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 1. be attached to this form to or less than 5 ppm,provided thatno other failure criteria are triggered._A copy of the analysis must . 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 surtace waters' due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution boX aboVe outlet" due'to an overloaded Or clogged SAS or cesspool Liquid depth in cesspool is less than 6".beIlow invert or available volume is less'.. than'.%Z;day flow- t5ns.doc tev.8/t6: Title 5 Official Inspection Forth:Subsurface Sewage Disposal Sysiem•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Scudder Ave. (2 systems at this props" this is the garage system) Property Address Boiardi Owner information Owner's Name is required for every page. Hyannis MA 02601 5/9118 City/Town State Zip Code Date;of Inspection B. Certification. (cont.) Yes No ❑ Required pumping more than 4'times in the last year NOT due to:clogged or obstructed pipe(s) Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 Any portion of a cesspool or privy is.less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality`analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must'be attached to this form.) The system is a'cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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 0 ❑ thesystem is within 406 feet of a surface drinking water supply ❑ ❑ the system,is within 200 feet of a tributary to a surface drinking water supply the:system is located in a nitrogen sensitive area (Interim Wellhead Protection. Area=IWPA)or a mapped Zone II of a public water;supply well If you have answered"yes"to any question in SectionE the system is considered a significant threaf,. or answered"yes"in Section D1 above the large system has failed. The owner or operator of any large ystem considered a significant threat,under Section E or failed under Section D shall upgrade the system.in accordance with'310 CMR 15304. The system owner should contact the appropriate, regional'office of the Department: 450 4oc rev.6116 ' Tdie 5 official inspection 6rm::9ubsurNOCSsws0e Disposal Systern•Page S of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 554 Scudder Ave. (2'systems.at this property this is the garage system) Property Address _ Boiardi Owner information Owners Name is required for every page. Hyannis MA 02601 5/9/18 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 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? El Z Hat the system received normal flows in the previous two week period? ❑ ® this inspection?Have large volumes of water been introduced to the system recently or as part of ❑ Were as built plans of the system obtained and examined?(If theywere not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage backup? El Was the site inspected forsigns of breakout? ❑ 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 ofliquid, depth of sludge and depth of scum? El 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 G is at issue approximation of distance is unacceptable)[310 CMR 1.5.302(5)] D. System Information Residential Flow,Conditions: Number of bedrooms desi n n/a 0 ( 9 ) Number;of bedrooms(actual): DESIGN flow based-on 310 CMR 15.203(for example: 11.0.gpd x#of bedrooms) n!a t5ins.doc'•rev.'6116 Titles Ofriaal lns =_ pection Ftirm:.Subsurface Sewage Disposal System Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage,Disposal System Form-Not for Voluntary Assessments 554 Scudder Ave. (2.systems at this property this is the garage system) Property Address Boiardi Owner information Owner's Name is required for every page. Hyannis MA 02601 5%9/18 . Citylrown State Zip Code Date of.Inspection D. System Information Description: System.is typical of:a 3 bedroom Number of current residents: 0. Does residence.have a.garbage,grnder? ❑ Yes No Is laundry on a separate sewage systern?(Include laundry system inspection information in this report.) ❑ Yes 0 ,No Laundry system inspected? ❑ Yes 0 No Seasonaluse? Yes: ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes 0 No Last date of.occupancy seasonal Date ommercial/Industrial Flow Conditions: Type of Establishment:. Design flow(based on 316 CMR 15.203): Gallons per day(gpd) Basis of.design flow(seats/personsfi§ ft., etc.y Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? El Yes ❑ No Non sanitary waste discharged to the Title 5 sysfem? ❑ 'Yes. 0 Noy. Water meter.re di If available: 5ns.doo'•rev.i6/76' Title 5 Official tnspeopn Fonn::SubWface Sage Disposat.System PsgO of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary.Assessments �e 554 Scudder Ave. 2 systems at this proptq this is the ara e system Property Address Boiardi Owner information Owner's Name is required for every page. Hyannis MA 02601 5/9/18 Cltyrrown State Zip Code Date of Inspection - D. System Information Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No recent pumping per 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 El Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation andmaintenance contract(to be obtained from system owner)and a copy of,latest inspection of the I/A system by.system operator under contract El Tight tank. Attach a copy of the-DEP approval. Other(describe):` t5ins.doc:•rev.6/16 Tile 5 oRcial Inspection FOW$Osurrace Sewage Disposal Sy iem•Page 8 of 17 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 554 Scudder Ave. 2 systems at this property this is the gara"e system) Property Address Boiardi Owner information Owners Name: ' is required for every page. Hyannis MA 02601 5/9/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.). Approximate age of all components, date installed (if known)and.source of information` 2007 per BOH record Were sewage odors detected when arriving at the site? Yes 0 No Building Sewer(locate on site plan): Depth below grade:: 12 feet. Material of construction: El cast iron ®40 PVC El other(explain);: Distance from private water supply well or suction line: >10" feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate;on site plan): Depth below grade:` 6" feet Material of construction: concrete ❑ metal ❑fiberglass 9 0 polyethylene H-10 tank El (explain). : If tank is metal, list age: years is age confirmed by a Certificate of Compliance?(attach'a copy of certificate) ❑ Yes: ❑ No Dimensions: 1500g Sludge depth` trace. t5ins.doc rev.6116 Title 5 Officid Inspedon Form:Subsurface Sewage Disposal System-Page 9 of iT Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Scudder Ave. 12 systems at this property this is the°2 ra a system) Property Address — Boiardi Owner information Owners Name is required for Hyannis H every page. y MA 02601 5/9/18 Cityrrown 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 >12' Scum thickness trace . Distance from top of scum to top of outlet tee or baffle '2 >2„ Distance from bottom of scum to"bottom of outlet tee or baffle 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.): Pumping suggested every 3 yearn to proton the life of the system Grease Trap(locate on site plan): Depth below grade` feet Material of construction: ❑ concrete 'metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scurn thickness Distance from too of scum to top of outlet tee or baffle Distance from.bottom of scum to bottom of outlet tee or baffle Date of last pumprng;., Date t5insd9r-rev.6116 Tttle'50rficial t6spedw forth:subsurface Sewage Disposal System Page!O of'17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-' Not for Voluntary Assessments M 554 Scudder Ave. (2 systems at this property this isthe garage system) Property Address Boiardi Owner information Owners.Name is required for Hyannis MA 02601 5/9/18 every page. Y 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 below grade: 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 ❑ Nd t5insidoc"-rev.E f16 Tim 5 official_Inspechon Form.Subsurface:Smage. sposal System•Page±11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form—Not for Voluntary Assessments 554 Scudder Ave. (2 s'stems at this property this is the garage system) Property Address Boiardi Owner information Owner's Name is required for Hyannis every page. MA 02601 5/9/18 Cltyrrown State Zip Code Date of Inspection D. System Information (c(jnt.) 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.): H-10 d-box is 2'6."below grade, cover raised to 6" very good condition 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 arid.appurtenances, etc.,): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption,-System (SAS) (locate on.,site plan, excavation not required): if SAS`not.located, explain why: i5ins,i7oc rev.6f1fi Title 5 Offidal Inspection Form.Subsurface Sewage Disposal System r Peg e'12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Scudder Ave. (2systems at this property this is the'garage system) Property Address Boiardi Owner information. Owner's Name is required for page. every Hyannis p g MA 02601 5/9/18 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number; length: ❑. leaching fields number, dimensions: overflow cesspool number El innovative/altemative system Type/narnd of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc:): Chambers were video inspected and are dry at this time, top of chambers is 2'6" below grade; no indication of past hydraulic failure 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 k5in5.doc. rev;.6116 Title 5 Official Inspection Form:Subsurface'$ewage Disposal System'.Page 13 of'17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for VoluntaryAssessments:ents M 554 Scudder Ave. (2 systems at this property this is the garage system) Property Address Boiardi Owner information Owner's Name is required for every page. Hyannis MA .02601 Cltyrrown 5/9%18 State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Soils are compact and dry Privy(locate on site plan): Mateeials of construction; Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding condition of vegetation, etc.) t5ins.doc•rev.6/16 Title 5 official im cfion Forrtn:Subsu ace Sewage Disposal System=Page_14 cf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments 554 Scudder Ave. (2 systems at this property:this is the gara9d system) Property Address Boiardi Owner information Owners Name is required for every page. Hyannis MA 02601 5/9/1.8 Citylrown State Zip Code Date of Inspection D. System Information (eont) 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 ------------ b l `(3 C- C3 �s cry I 15ins.doci rev.6116 -h SOfficial Inspecti.an Form:Subsurface.Sewage DisiJwal:Systdhi•Page 15 of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Scudder Ave. (2 s)Ltems:at this property this is the garage system} Property Address Boiardi Owner.information Owner's Name is required for Hyannis MA . 02601 every page. Y _ Cityrrown State Zip`Code Date of Inspection D. System Information (font) Site Exam: Check Slope. F Surface water 0 Check cellar n Shallow wells Estimated depth to high ground water: >1 Q' 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: Dat6 NGVV 126" Date ❑ Observed site labutting propertylobservation`hole within 150 feet of SAS) Checked with.local Board of Health-explain' . 4'seperation per 2007 compliance Check.ed with local excavators;installers_(attach documentation) Accessed USES database: explain, TOPO mapping: You'must describe how you established the High ground water elevation.:. Site is 224msl and nearby water 5'msl Before filing this Inspection Report,please;see Report Completeness<Checkhst on..next page: a ,t . y t5ins:doc•rev.:6116 ' Tille'S`Official Inspection Form:SubsuRaceSewage Disposal System Page;16 of 17` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-:Not for Voluntary Assessments 554 Scudder Ave. (2systems at this property this is the garage system) Property Address Boiardi Owner information Owner's Name everypage.required for Hyannis MA 02601 6/08 . e Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached'in separate file 45ins.doc•rev. (5 Tide 5 6ffi6il Insped nFdim:Subsurface'Sewago Disposal system Page i17 of:17 TOWN OF BARNSTABLE LOCATION S Sc v r .A,,e wlAQA6 SEWAGE# ;00 ST-7 VILLAGE "AIA ASSESSOR'S MAP&PARCEL o7S�P �S INSTALLERS NAME&PHONE NO. .9f,^; 5 i a SM77J-I '7,b SEPTIC TANK CAPACITY LEACHING FACILITY: (type)_9X-5M Q�y&-d ls .. (size) Id,r)r NO.OF BEDROOMS . D'- 6A /a&r, e OWNERtnre�� � PERMIT DATE: COMPLIANCE DATE: /J moo Y Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 3 f Feet Private Water Supply Well and Leaching Facility(If any wells exist IJ 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 /a/,r .P0o 5A,$ A�q: No. GD 7 Sq ! Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYication for �Mpo!6a[ *pztem Coi%tructiott Vermtt Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System p❑Individu^a-ll Components Location Address or Lot N n`5 1 Owner's Name, ddress,apd Tel.No.S0�"�7 S5N SCv&eX �. � M(NIS ` Moir) 'PX,),er _ Assessor's Map/Parcel a$`1 J IS- (f H�5.� d LA/ "�-n i Installer's Name, ddress 8TAO and Tel.No. Designer's Name,Address and Tel.No. 50&_-N (f-01319 M 6 1\& Sr �L L✓c�0 —;�Ccl, 0 3�t M �� die, r.l l2 C►rc,1e c ��c�, Type of Building: '''''' �C•CrC1t�. Dwelling No.of Bedrooms 0 Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) -n51 d& c3ntk� �Iar,S of Flo- lets^, # �T aqaLI, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environ ntal Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of HeAkh. Signed Date Application Approved by� Date / L q—r Application.Disapproved by: Date for the following reasons Permit No. r7 Date Issued 3 � z • _ "�,,,'�Ls.,v,r_,:.M- .,-,.� rr c'r��� - t- CA r -or . V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppricaction for 3h5posal *p!tem Cow6truction Permit Application for a Permit to Construct O Repair Upgrade O Abandon( )�� Complete System ❑Individual,Components r- - p ^� p n Location Address or Lot 1,o. Owner's Name, ddress,and Tel.No.sd 4"7 7�w Ora Assessor's Map/Parcel 01 (i H .5 UQ/o , yQ,,((Y)0 1n`• 'C" Installer's Name,Addressd and Tel.No. Designer's Name,Address and Tel.No. G�rC � Type of Building: Lor Cr °' I��� %,I,t�,, Dwelling No.of Bedrooms '% Lot Size sq. ft. Garbage Grinder ( ). Other Type of Building No of Persons Showers( ) Cafeteria( ) Other Fixtures ' Design Flow(min.'required): gpd Design flow provided gpd Plan Date. Number of sheets Revision Date tr, Title Size'-of Septic Tank Type of S.A.S. (Description of Soil r' Nature of Repairs or Alterations(Answer when applicable)_770,SV&_U 0., c-),e� i f*I e. 15-. o,Date last inspected: Agreement: f The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environ ntaI Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He Ath. d Signed /� /_ Date `7 Application Approved by y}yf Date Application..Disapproved by: Date . for the following reasons Permit No. 1)_00-ri r-7 Date Issued ---------------------------------------------- ,u THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS tertifirate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ("� ) Upgraded ( ) Abandoned( )by ,. M �!1��\,.C��� N� d S{{�( t G„ at55H &P_W- I�Q TLt I`OCt Y1f� 1 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer. #bedrooms tApproved des',gn ow gpd The issuance of this permit shalLnot be con rued s rguarantee that the system w'i I functi n'a3s designed. Date _ _. Inspector ———— q—n----------- --------------------_-- - No. G`.(�n - THE COMMONWEALTH OF MASSACHUSETTS G,,,. PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Mis;po5al *p5tem Construction Permit Permission is hereby granted to Construct ( ) Repair (14 ) Upgrade ( ) Abandon ( ) System located at -55 w t-4c_l _ t'11t`i_n U-(_ � &A(`k _F f and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date / V /� Approved by�_ --� _T0 :ofBarngtible tory er-vices- -_ cr�ursz s . Thormas F Geller,Director' : :. :Public:Health-Division. . Thomas McKean;.Director - - :- 7 -1 -Sheet 101yanni%MA.0201 .-.0ffice::508-862=4644 Fax:_508-790-6304 lnstaller-&Designer-Certification-Forte: Sew ePermit#- - �essor's,MaplPareei ` Install Designer:. Cd kb �. � �. . Address::: : 9��..�� on lid l�l" .�1- .fed - (date)-.. (installer) {��; a perms " .t-to:.mstall a _ -septic:systeurat' based on::a desi I-certify-thatahe sept�caysteni.refeten ed.above was:b lled'.siiU t�ti Taccflrdingao:::::- the'deagn;:which may_mclnde:i�nor.:approved changes=such:as.lateral:"" ocaiou--of the': -- distiibution-box=a id/or_septic tack:: q. that:the:s tic: referenced--above:eras":installed_with:inn or:changes: i e - certify eP _ J . the SAS orany vertical:relocatiou.of-anycoaiponent..::.-:.:-:~.::::,::..: of ttie septic syste�ri)but"in accoidauce with`State= 'Local Regda iens..-Play rev�sZon_or certified as-built by.designer to-Mow. : ...------- .� c -. o�'��QAVIQSs�ys ". D. - .. -:? COUGHANOWR . . .. . staller's . . . . ::`(Installer's�lgIIatuTe). - .. -- N S9Nl TAR�P� esi er's Si Affix=Desi er.s_Stam Here : CD �.... Vie).:::: _ g° .-..p:... ) SE..- F��TIIR ::::TO BAR�TSTABLE: t'UBLIC:::HEALTH". DIV1M0N. :::`.CERTiFICATL: :0�:.:::. :::COMPLIANCE--WILL..NOT..BE...ISSIIED..UNTIL BOTH.TSLS=FOI2l�.AND AS-EUiLT:C�RD:-ARt+: : Q Heatth/SepticlDesigaer.Certification"Fa-riri3=Z6 _doc: C I (508)1162-4025 FAX(508)790 6230 PAUL ROMAU BUILDING INSPECTOR I� TOWN OF BARNSTABLE V 1 �{_. J AV REGULATORY SERVICES BUILDING DIVISION TOWN OFFICE BUILDING 1 200 Main Street,Hyannis,MA 02601 '7 email:paul.roma@town.barnstable.ma.us �-2-- D RECREATION c ROOM l CC, A7 2k2 L C _ O BATH • © � o..J �� � �� 0 0 PROPOSED SECOND FLOOR PLAN 1/4" = 1'-0" ' hoc u "'-- 1 r r,;q Z I I r- r I I$'X32' r SWIMMING POOL PROM r 4 � I SITE PLAN OF LAND - 554 SCUDDER AVENUE I" = 20'-0" i Town of Barnstable P# Ji2�03�1 dye' Department of Regulatory Services Public Health Division Date -�Ib v 200 Main Street,Hyannis MA 02601 _ Date Scheduled - Time 1 Fee Pd. i Soil Suitability Assessment for Sewage Disposal Performed By: U t D CoV G H A Q d Witnessed By: u k KI-a 2 40 D► LOCATION& GENERAL INFORMATION Location Add s Owner's Name ' 5ST SGuWer Ave I�rllo ��c�6anili ©tctrd� Address G 54 s vetd er A v( N Y,10141 5 MIA Assessor's Map/Parcel: 5 Engineer's Name 1 COO'��IGjGipy'/ NEW CONSTRUCTION - REPAIR-1 - Telephone# +S19'67 Land Use S1 r Slopes(% !D µ Surface Stones Distances from: Open Water Body 00+ ft Possible Wet'Area 10 00 t ft Drinking Water Well I Oo+ ft s Drainage Way S 0 t --e- ft Property line l rJ + ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) ER _AVENUE�� U 1 GROUNDWATER ADJUSTMENT EXISTING GROUNDWATER LEVEL I BASED ON TOWN OF BARNSTABLE �� 11 GIS DEPARTMENT RECORDS. r 1 I INDICATED GW 4.00 INDEX WELL M1W-29 s I I ZONE A READING DATE NOV. 2007 READING 9.7 1 ADJUSTMENT 2.7 —� ADJUSTED GW 6.7 I �� 161.12 Ft --------------- Parent material(geologic) a� Depth to Bedrock Depth to Groundwater. Standing Water in Hole: t r �� Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: �i OUP Depth Observed standing in obs.hole: In. Depth to sell mottle: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment Index Well# Reading Date: Index Well level-.�,-�-- Adj.factor-,_- . Adj.Groundwater Level,,, PERCOLATION TEST Bata iZ/tV0 Time �o M Observation Hole# d Time at 411 Depth of Pere Time at 6" Start Pre-soak Time '1 i 11 Time(9„-6 ) - End Pre-soak Rate MinJlnch S.M P l Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back=-------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTlMERCFORM.DOC SOIL TEST LOG - -- DATE OF TEST: DECEMBER 13. 2007 APPROVED SOIL EVALUATOR: DAVID D. COUGHANOWR. #461 WITNESSED BY: . y DONNA MIORANDI. ,HEALTH DEPT. PERC NUMBER: 12038GRO ; TEST PIT I PAORENTUMATERIEAL EPROGLAC ALD DUTWASH t PERC AT 52 to - 3 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL _ OTHER 25.60 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING ` .� 0-7 Ap - LOAMY SAND- 10 YR 3/2 ' NONE FRIABLE j . 7-30 B LOAMY SAND l 10 YR' 4/6 NONE FRIABLE 23.10 - _ . I 30-129 C -- — MEDUIM SAND- -- -'lm-YR .5/4 NONE LOOSE 14.85 NO-GROTEST • PIT 2 PARENT MATERIA ENCOUNTE PROGLACA LED OUTWASH i -'3'MIN/INCH IN C SOILS _ Y ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 25.90 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 0-6 Ap LOAMY SAND 10 YR 3/2 NONE FRIABLE B-32 B LOAMY SAND 10-YR 4/6 23.23 NONE FRIABLE 32-126 C MEDUIM' SAND 10 YR 5/4 NONE LOOSE - — 15.40 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. nitec Gravel) '1 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. n t Flood Insurance Rate Mav: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No✓ Yes Depth of NaturallY Occurring;Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Y°5 _— If not,what.is the depth of naturally occurring pervious material? ._..�.._..�. Certification 1q I certify that on V (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consist a t the required training,expertise and experience described in 310 CMR 15.017. � jN OF Mgss9c r!�CQ"61 Q°c. i Wb DAVID yG� Signature%w�,I mate D. COUGHANOWR cn 00 410ENSEA Q Q:\SEPT(C�PERCFORM.DOC /� P�o B V A l ;i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �n Property Address: 554 Scudder Avenue = Hyannisport = � Owner's Name: Robert Kennedy Jr Owner's Address: _^ �� a € " Date of Inspection: b � �0w Name of Inspector:(please print) W i 11 jam E_ • Robinson sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville, MA Telephone Number: (5 0 81 7 7 5—8 7 7 6 CERTIFICATION STATEMENT 1 certify that 1 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 Se tion 15.340 of Title 5(310 CMR 15.000). The system: ses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �, L ,,.� 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 approxing authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 I Page 2 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 554 Scudder Avenue Hyannisport Owner: Robert Kenned Jr Date or Inspections Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 6 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Pa ses: One or more system co onents as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon com etion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined ,N,ND)in the for the following statements.if"not determined"please explain. The septic tank is metal and o er 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltrad n or exftltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a comp l ' g septic tank as approved by the Board of Health. •A metal septic tank will pass inspecti n if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 ears old is available. ND explain: Observation of sewage backup r break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a broken, ttled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ken pipe(s)are replaced bstruction is removed distribution box is leveled or replaced ND explain: The system required pumping m e than 4 times a year due to broken or obsuixied pipe(s).The system will pass inspection if(with approval of the Bo d of Health): broken pi e(s)are replaced obstructifla is rcmovod i ND explain: I. Pag€3ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 554 Scudder Avenue Hyannisport Owner. Robert_ Kennedy Jr Date of inspection: C. Further Eval ion is Required by the Board of Health: Conditions cxi t which require further evaluation by the Board of Health in order to determine if the system is failing to protect pu lic health,safety or the environment. 1. System will pa s unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not f ctioning in a manner which will protect public health,safety.and the environment: Cesspool o privy is within 50 feet of a surface water Cesspool o privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fa unless the Board of Health(and Public Water Supplier,if any)determines that the system is functions g in a manner that protects the public health,safety and environment: _ The syste has aseptic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water pply or tributary to a surface water supply. _ The cyst in has a septic tank and SAS and the SAS is within a Zone I of a public water supply. — The sys em has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. The sys em has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a private wale' upply well•• Method used to determine distance •This system asses if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and vo the organic compounds indicates that the well is free from pollution from that facility and the presence of moma nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria triggered.A copy of the analysis must be attached to this form. 3. Other: I� 3 i Page 4 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 554 Scudder Avenue Hyannisport Owner: Robert Kennedy Jr Date of Inspection: 5i''—).f-G 51- D. System Fail re Criteria applicable to all systems: You must indicate -es"or"no"to each of the following for all inspections: Yes No _ Backup o ewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SA or cesspool _ Static liquid evet in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth' cesspool is less than 6"below invert or available volume is less than%day flow Required pump g more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumpe Any portion of t SAS,cesspool or privy is below high ground water elevation. Any portion of ce spool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. Any portion of a c sspool or privy is within a Zone I of a.public well. Any portion of a cc spool or privy is within 50 feet of a private water supply well. Any portion of a cc spool or privy is less than 100 feet but greater than 50 feet from a private Kater supply well with no acceptable water quality analysis.(This system passes if(lie well water analysis, performed at a DE certified laboratory,for coliform bacteria and volatile organic compounds indicates that the ell is free.from pollution from that facility and the presence of ammonia nitrogen and nilra nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A co y of the analysis must be attached to(his form.) (Yes/No)The system f its.I have determined that one or more of the above failure criteria exist as described in 310 C R 15.303,therefore the system fails.The system owner should contact the Board of Health to doermin what will be necessary to correct the failure. E. Large Systems: To be considered a large s tern the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes" r"no"to each of the following: (rite following criteria apply to 1 ge systems in addition to the criteria above) yes no the system is within 400 f t of a surface drinking water supply the system is within 200 fee of a tributary to a surface drinking water supply the system is located in a nitro en sensitive area(interim Wellhead Protection Area—1WPA)or a mapped Zone ll of a public water suppl well If you have answered"yes"to any question in Sedim E du system is considered a significant ducat,or answered "yes"in Section D above the large system fined.The u%mcr ar operator of arty large system considered a significant threat under Section E or failed er Section D shall upgrade the system in accordance with 310 CM 15.304.The system owner should contact the propriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 554 Scudder Avenue Hyannisport Owner: Robert Kennedy Jr Date of Inspection: K O,f-13— Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No/ V 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? I,/_ 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? V _ 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: Yes no _/ 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(3)(b)] 5 Page 6 of 11 ` V OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASS SSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO FORM PART C SYSTEM INFORMATION Property.Address: 554 Scudder Avenue Hv p annis ort _ Owner: Robert Kennedy Jr Date of inspection: ~1 -0 51 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 5.203(for example: 110 gpd x#of bedroo Number of current residents: N Does residence have a garbage ' der(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspe lion required] Laundry system inspected(yes or no): J Seasonal use:(yes or no): Water meter readings,if av rlable(last 2 years usage(gpd)): 2 0 0 4 15 0 0 0 Sump pump(yes or no):._A-v 2 0 0 3 - 6, 0 Last date of occupancy: COMMERC'A NDUSTRIAL Type of establis ent: Design flow(b don 310 CIvIR 15.203): gpd t O Basis of design ow(seats/persons/sgft,etc.): Grease trap pre ent(yes or no):_ Industrial wast holding tank present(yes or no):_ Non-sanitary aste discharged to the Title 5 system(yes or no):_ Water meter r adings,if available: Last date of o cupancy/use: OTHER(describe): GENERAL INFORMATIO Pumping Records Source of information: 4 '�r X e 2-- i� 0. s Was system pumped as part of the inspection(yes or no): &!�O If yes,volume pumped:__gallons--How was quantity pump d determined? Reason for pumping: TYP OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspecti records,if any) _Innovative/Alternative technology.Attach a copy of the ent 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 own)and source of information: Were sewage odors detected when arriving at the s' a(yes or no): i 6 Page 6 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 554 Scudder Avenue H_yannisport Owner: Robert Kennedy Jr Date of Inspection: -^/ —6 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Z Number of bedrooms(actual): y_ DESIGN flow based on 310 Cki 5.203(for example: 110 gpd x 4 of bedrooms): y Number of current residents: Al' d w Does residence have a garbage er(yes or no):&0 Is laundry on a separate sewage system(yes or no):mac!(if yes separate inspection required) Laundry system inspected(yes or no): i) Seasonal use:(yes or no):140 Water meter readings,if avidlable(last 2 years usage(gpd)): 2004 15 000 Sump pump(yes or no): Last date of occupancy: COMMERCIA NDUSTRIAL Type of establis ent: Design flow(b don 310 CMR 15.203): _gpd Basis of design ow(seats/persons/sgft,etc.): Grease trap pre ent(yes or no):_ Industrial wast holding tank present(yes or no): Non-sanitary aste discharged to the Title 5 system(yes or no): Water meter r adings,if available: Last date of o cupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_ / 4 q "y x a .V w e Was system pumped as part of the inspection(yes or no): > If yes,volume pumped:__gallons—How was quantity pumped determined? Reason for pumping: TYP 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: Were sewage odors detected when arriving at the site(yes or no): i(� Page 7 of I I ,I OFFICIAL INSPECTION FORA'I—NOT FOR VOLUNTAItY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C SYSTEM INFORMATION (continued) Property Address: 554 Scudder Avenue Hyannisport Owner: Robert Kennedy Jr. Date of Inspection: DUILUING SE1VE (locate on site plan) Depth below gra Materials of eo truction:_cast iron _40 PVC_other(explaus): Distance fron private water supple well or suction lute: Comments(on condition of jousts,venting,evidence of leakage,etc.): SEPTIC TANK: V(locatc on site plan) Depth below grade:_I Material of construction:_✓concrete metal fiberglass__,olyetlsylene _odxr(explain) If Lank is metal list age._ Is age confsnned•by a Certificate of Compliance()-es or no):—(attack a copy of certificate) s Dimensions: `'`" ('. Sludge depth: /—,�Z Distance from top of sludge to bottom of outlet tee or baffle: _ Scups thickness:_,C) _ Distance from top of scum to top of outlet tee or baffle: s Distance from bottom of scum to bonom.,gf outlet tee or baffle:/ s I low were dimensions docnnincd: (I Th,_4 Comments(on pumping rccommcndations,inlet and outlet tcc or bafllc condition,structwal integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): P 1+ .I/ GREASE TRAP:_(local on site plan) Depth below grade:— Material of eonstruetiot _concrete metal fiberglass lsolyethylene_otlser (explain): — Dimensions: Scum thickness: Distance Gom top of scum to top of outlet tee or baffle:_ Distance from b tom of scum to bottom of outlet tee or bailie: Date of last put ping: Conuncrits(o pumping rccommcndations,inlet and outlet Ice or bathe condition,structural integrity, liquid levels as related to oullct invert,evidence of leakage,ctc.): 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORIIIATION(continued) Property Address: 554 Scudder Avenue Hyannisport Owner: Robert Kennedy Jr. Date of lospcctloo: ZLZd—o S— TIGHT or 11OLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dcpth below grade: Material of construe ton:_concrete_metal_fiberglass pulyethylene otller(explaul): Dimensions: - Capacity: allons Design Flow:j gallons/day Alarm prescnt ycs or no): Alarm level: Alarm in working ordcr(yes or no): Date of last mping: Comments ondition of alarm and float switches,etc.): DISTRIBUTION BOX: (if prescnt must be opcned)(locate on site plan) Depth of liquid level above outlet invert: Conuncnts(note if box is Ievcl and distribution to outlets equal,an)-evidence of solids carryover, any evidence of leakage into or out of box,etc.): n l� PUMP CHAMBER: (loc c on site plan) Pumps in working order(yc or no):— Alarnts in working order cs or no): — Conuncnts(note eoltdill l of pump chamber,condition of pumps and al)purtenanccs,etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 554 Scudder Avenue Hyannispor Owner: Robert Kennedy Jr Date of Inspection: K— d f- SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type , eaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: t 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,damp soil,condition of vegetation, etc.): lS �L 4 �✓ ���7 / �' V t� �ib 1��y� CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and co figuration: Depth—top of squid to inlet invert: ` Depth of soli layer: Depth of scu layer: Dimensions of cesspool: Materials construction: lndicatio of groundwater inflow(yes or no): Comme s(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: /ns ate on site plan) Materials ofuction: Dimensions: Depth of s( ids: Comment (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I l i OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 554 Scudder Avenue Hyannisport Owner: Robert Kenne_4y Jr Date of Inspection: lS-6 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. 15- (/ n � 10 I Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 554 Scudder Avenue Hyannisport Owner. Robert Kennedy Jr Date.of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water S feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓Checked with local Board of Health-explain: 7e;r-x G jqe)s 3 aZ o t� Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: r'\ You must describe how you established the high ground water elevation: 136 —/7i�sTo o /no �T 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE:OFFICE OF:ENVIRONMENTALAFFAlRS _= DEPARTMENT OF ENVIRONMENTAL PROTECTION -IREC�IVE® MAR 2 8 2003 TOWN OF BAPNSTABLE HEALTH DEPT;, TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM = PART A CERTIFICATION Property Address: 554 Scudder Ave MAP Hyannisport PARCEL Owner's Name: Richard Karris LOT Owner's Address: -- - Date of Inspection: Name of Inspector:(please print) Wi 1 1 i am E - Robinson Sr. Company Name,: . William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville'. MA - Telephone Number: ( 508) _ 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and.complete as of the time of the inspection.The inspection was performed based on my training.and experience in the,proper function and maintenance of on site sewage disposal systems.1 am a DEP approved system inspector pursuant to Section,15340 of Title 5(310 CMR 15.000) The system: l/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails d L Inspector's Signature: L a � Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heawor' DEP)within 30 days of completing this inspection.If the system is a shared system or bas 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 approxing authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPEECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL�SYSTEM INSPECTION FORM PART A CERTIFICATION (continued): 554 Scudder Ave Property Address• rya—ffn Ssport is ar Karris Owner. Date of Inspection: Inspection Summary::Check A,B,C,D or E/ALWAYS complete. 11 of Section D A.j System Passes: thave not found any;information which indicates not evaluated e f a7liure criteated ria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria Comments: _ r TB. Syvstem 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. 1 in the for the following statements-If"not determined"please Answer yes,no or not determined(Y,N,ND) explain. The septic tank is me tal and over 20 years old*or the septic tank(whether metal or not)is structurally the unsound exhibiu substantial infiltration or.exfiltiation or tank failure is imminent System will pass inspection i 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 indicatir g that the tank is less than 20 years old is available. ND ex,lain: Observation of sewage backup or break out or high static water level in the distribution box due Mbroken or obs cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with a roval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is rtmovcd ND ex lain: Page 3 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS . , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION(continued) Property Address: 554 Scudder Ave 1►annispor ; Owner: Richard Karris ..... . ....:.... _ Date of Inspection: L`,/ C. Further Evaluation is Required by the Board of Health: 1 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is ailing to protect public health,safety or the environment 1. System will pass unless Board of Health determines id 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. eetof 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 stem is fu"tWning 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 aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well".Method used to determine distance ••This system passes if the well water analysis,performed at DEP certified laboratory,for coliform --.bacteria.bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and,. the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM •'PART A , CERTIFICATION(continued) 554 Scudder .Av e Property Address: Hyannisport is arCTKarris Owner. ..... . Date of Inspection: D System Failure Criteria applicable to all systems:. . Yo must indicate"yes"or"no"to each of the following for all inspections: Yes No J 8-AS:or cesspool Backup of sewage into facility or system component dace of due to ound or surface a waters e to an overloaded or Discharge or pondingge g of effluent to the surf . .. ground, . clogged SAS or cesspool _ Static liquid level in the distribution box above outlet invert due to n overloaded or clogged SAS or I cesspool Liquid depth in'cesspool is Tess 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 I of times pumped Any portion of the,SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. An , 'onion of a cesspool or privy is within 50 feet of a private water supply well YP f 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility ro a the nd that no of a failure criteria ont nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,p are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exisf as 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: T6 be considered a large system the system must serve.a facility with a design [low of 10,000 gpd to 1'S,000 pd. ou must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) y s 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 sipliftcant threat.or answered if you have answered"yes"to any question in Bettina E the system is considered a kar e system considered a "yes"in Section D above the large system has failed.The owner or operator of any g Y 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. �- - 4 gage 5 of I 1 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , . PART B CHECKLIST Property Address: 554. Scudder Ave yannispor Owner: Richard Karris Date of Inspection: 1�-- Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes Noj 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? V_ Has the system received normal flows in the previous two week period_;? L/ 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) I/_ Was the facility or dwelling inspected for signs of sewage back up? t, _ Was'the site inspected for signs of break out? L// _ 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-t/he baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? y_ Was the facility owner(and occupants if different from owner)provided Withinformation on the proper maintenance of subsurface sewage disposal systems.!, The size and location of the Soil Absorption System(SAS)on the site has been determined based on:. Yes no / Existing information.For example,a plan at the Board of Health. _L11 Determined in the field(if any of the failure criteria related to Part C is at issue approximation-of distance is unacceptable)(310 CMR 15.302(3)(b)) 5 Page 6 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART,C. SYSTEM INFORMATION Property Address: 554 Scudder Ave Ricliard Owner: Date of Inspection: 6 3 FLOW CONDITIONS RESIDENTIAL. ... Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): j G 6 Number of current residents: 7 Does residence have a garbage grinder(yes or no):lL v is laundry on a separate sewage system(yes or no):4-6[if yes separate inspection required) Laundry system inspected(yes or Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)):' 2 0 0,1:.-2 0 0 2: 1 1.0, 0 0.0. gal s Sump pump(yes or no):L Last date of occupancy: CO MERCIAIANDUSTRIAL Type o establishment: Design ow(based on 310 CMR 15.203): "d Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date f occupancy/user OTHER describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): /b Cl If yes,volume pumped: Rallons-=How was quantity pumped determined? Reason for pumping: _ %✓U TY E OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Pnvy _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) _Tigbt tank —Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):,k 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT*FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM` PART C SYSTEM INFORMATION(continued) Property Address: 554 Scudder Ave L- TJ.� Owner: Ric - — Date of inspection: '3 BU DING SEWER(locate on site plan) Dcp below grade: Mate ials of construction: ' cast iron _40 PVC_other(explain): Dis cc from private water supply well or suction line: Comm nts(on condition of joints,venting,evidence of leakage,etc.): z SEPTIC TANK:2(locate on site plan) Depth below grade: Material of construction: /Zconcrete_metal fiberglass_polyethylene _other(explain) If tank is metal list age:— Is age confirmed-by a Certificate of Compliance(yes or no):__ (attach a copy of certificate) i '[ Dimensions: ;: x G Sludge depth:_ y Distance from top of sludge to bottom of outlet tee or battle: Scum thickness: Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:_ O �.z J Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): i i I i / /c"�fl P� C� i �� ^ �/ �' ✓� ��( [� / , A �/ Coo G EASE TRAP:_(locate on site plan) Dep below grade:— Mate 'al of construction:_concrete - metal fiberglass_polyethylene_other " (expla ): _ Dime ions: Scum hickness: Dista a from top of scum to top of outlet tee or baffle: Distal cc from bottom of scum to bottom of outlet tee or baffle: Date Of last pumping: Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as r ated to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM INFORMATION(continued). 554 Scudder Ave Property Address: Owner: ar arris Dale of Inspection: 71' TIG Tor HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan).. . Depth Blow grade: Materi 1 of construction: concrete. metal fiberglass_polyethylene other explain): Dimen ions: Capaci gallons Desig Flow:_ gallons/day Alarm present(yes or no): AI level: Alarm in working order(yes or no): Date f last pumping: !J.�enls(co�nliionof alarm and float switches,etc.): DISTRIBUTION BOX: �f present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ej Comments(nose if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps i working order(yes or no): Alarms n working order(yes or no): Comore is(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION.FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 554 Scudder Ave Owner: Rtutiard Date of Inspection: G_3 SOIL ABSORPTION SYSTEM(SAS): /%locate on site plan,excavation not required) If SAS not located explain why: A Type� p i/leaching pits,number: leaching chambers,number: leaching galleries,number: 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.): // _ CESSPOOLS:�_(cesspool must be pumped as part of inspect ion)(]ocate on site plan) Number and conft,goration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layI r. Dimensions of ces�pool: Materials of construction: Indication of grow dwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I PRIVY: (loiate on site plan) Materials of cons ction: Dimensions: Depth of solids: Comments(not condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of l 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY UNTARY ASSESSMEN E SEWAGE TS GE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 554 Scudder Ave Property Address:,,an Gnw - Owner. S Date of Inspection: 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. g Ss, C� o i ui i 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 554 Scudder Ave Property Address• }sPe Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water /!� feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hol�Xithin,1.50 feet o AS) Checked with local Board of Health-explain: /�i�' t J�<i� �G/�°a� Lw I �08 Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Y y M 11 5` l y73 L O=.Cf ' 10 �"�.�� C UC�LIc� 1� SEWAGE PERMIT E�0. VILLAGE I N S T A LLER'S NAME A ADO ESS i U I L 0 E R OR kA e- DATE PERMIT ISSUED k-c> D_�l DAT E COMPLIANCE ISSUED �ad�8� L7CvU�c Avc� ro - J �rsfiAil k— Z o3 1 t. G¢* THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH - Town..0F......Barn Appliration fnr Disposalstable..... Works Tnnstrur#inn umit Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal System at: 55ZI;..Scudder„Ave:s..H1'. W.1appmt..---M1......----•---•-•---..... -•---•--•------------------------------•---•--._......................................-•--------- Location-Address or Lot No. George„Kazis___ 51_Scudder 1�ve_t,,,,, jr�nni �ort,___M.Q____„_ ...............•.......---•--........-----------...------•--........ ........ Owner Address a A &_ B Cesspool_Service .128 Bishoys,Terrace,--Hyannis,__MA-----02601____ Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...............3...........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons...... ................... Showers — Cafeteria Q, Other fixtures ---------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_............. Depth................ x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area.....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY------•---•--••----------•-------•----.••---------------------•--•-.•---- Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water................... (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___._____-.--__-_-___ a •-•••---•...•-•----------------•-••...--••••----.................-------•-...........------.................................................................. 0 'Description of Soil.....................••-•-•--•-•-----•---•-•--••-------.......-----------•-•---------------------------•----•-------------------------------------------..............-- x W ----•-•--------------------------------------------------•---------••-----------._.......--•-•--•---------•-•=------------------------------------••------••-----•-..:_.._......•-••-----------•-------- UNature of Repairs or Alterations—Answer when applicable. nstallatiozU__of_.a-- ink, 1 distribution._box-and,_.. ... 00... gallon;_leach__pit__(overflow_ __________________________________________________________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITl12, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Ven issued by the boar of lth. Signed.... _.. - 8�2081......... Date ApplicationApproved By................................................................................................... ..............8/20 .8....------ Date Application Disapproved for the following reasons:-------•-------------------••---------------....--------------------------------•---....._............-•-••-••-- ................•---•-......--......----......--•--••--•-•---.............-•----------.........-----•--..._..............._..---.....------•-------.----- .---------------------------------------...... Date Permit No..8.:.........-•--•-••.-•-•-�7�............ Issued.....8120181................................. Date No...0 `YAFps... ..LIQ....._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T own.-.c)F.....Barnstable ------------------------------------------------------------ ApptirFation for Disposal Works Tnnstrnrtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal System at: 554..Scudder -A v.e.....,..Hyannis�ort_„_.!`?A................. ........ ................................................Lo .N.............._...._.........._............_. Location-Address or o George•.naris _554.Scudder Ave., Hyannisport, MA.................. - Owner Address a A 1, R--Cesspool-_Service_ 128 Dishops Terrace, Hyannis, TfA 02601 Installer Address Type of Building Size Lot.... .....................Sq. feet ag— .____Expansion Attic ( ) Garbage Grinder ( )Dwelling No. of Bedrooms_______________ ______________________ — pa Other—Type of Building ____________________________ No. of persons............................ Showers ( ) Cafeteria ( ) PaOther fixtures ------------------------•--------------------- -----------------------------------------------------------------------------••-••-------•••...__.. w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................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........................ a ---------------------------•--------•------- ..__.....------------••-•....--•---.....•........................................................ 0 Description of Soil........................................................................................................................................................................ x w UNature of Repairs or Alterations—Answer when applicable. nstallation of a .1_,000_gallon septic tank, 1 distribution box and a-1,000 gallon leach•-pit (overflow -------••------------------------------------------- - ......................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en issued b}r'the b and of 1 8 20 81 Signed..................• .. f='r=N!- --- -- -- /_____------•-- & 81 ApplicationApproved By... =------------------------------------------•-----------------------------•--•- ........................................ Date t Application Disapproved for the following reasons:.............................................................................................................. ................•--=-•-----••-------•---.....__...--------------------•-•----------------•--•-------------•------------------------------------------------------------•--------------------- 81- 512 3 8�20/81 Date PermitNo.•-----•-----------=--------------------- ------------ Issued .......................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town .. Barnstable ........................................ a (Inrtif ir,tq of. T mj ftFanrr T 1 TO CER FY That h�I div•dual wa e Disposal S- tem nst ( red (X ) t�esspool ervice, �ts '�is ops�erra.ce, layan�i s, - �J�j� by-------••-----••---••-----•------------------••----•-------•-----•-----•-.._...........-•-••------•----------.-••------•••---•=-•......................... •...... ._-----------••--------------------- ; 554 Scudder Ave., Hyannisport, TEA 02%'�-- George Karis at.......--•--....------•--------------------------------------•----------- has been installed in accordance with the provisions of T61 LEE, r _ hq,State Sanitary Code, d�dribed in the application for Disposal Works Construction Permit No________________________________ ______ dated.---____._`:___..__________.______.__.______._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 8// 81 }� DATE.................................... ...............................•--------- Inspector............. ` l!,!........................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barn stable- 81- ...........................................oF.................................._.................................................. $ 5.00 No......................... FEE ... Disposal Works %T11notrnrtilan "train A & B Cesspool Service . Permission is hereby granted.............................................................................................................................................. to Constr p r - In�io Se ge System Suodde ve., y%annspi Ceo e Karis atNo..................................................................................................................................... ................................................... / stry 81 9/20/81 as shown on the application for Disposal Works Construction l,eerrni o______ ___________ Dated................................... ---------- ------p p C� /Ul Board of Health DATE-----------------------------------------------•---_..._. ----•-• FORM 1255 HOBBS & WARREN. INC., PUBLISHERS SOIL TEST LOG DESIGN CALCULATIONS DATE OF TEST: DECEMBER 13. 2007 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD APPROVED SOIL EVALUATOR: DAVID D. COUGHANOWR. #461 SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS WITNESSED BY: DONNA MIORANDI. HEALTH DEPT.PERC NUMBER: 12038 INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) DISTRIBUTION BOX: USE 3 OUTLET D-BOX, NO GROUNDWATER ENCOUNTER LD OUTWASH SOIL ABSORBTION SYSTEM: A 24 f L x 12.5 f t x 2 f t LEACHING GALLERY CAN LEACH TEST PIT PERC AT 52 in - 3 MIN/INCH IN C SOILS A Asdot w = ( 24 x 12.5 ) = 300 sf w = ( 24 + 24 + 12.5 + 12.5 ) x 2 = 146 sf ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER At.ot. = 446 sf (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING Vt 0.74 x 446 = 330.04 GPD 25.60 USE A 24 Ft x 12.5 FL x 2 ft. GALLERY. Vt = 330.04 GPD > 330 GPD REQUIRED 0-7 Ap LOAMY SAND 10 YR 3/2 NONE FRIABLE 7-30 B LOAMY SAND 10 YR 4/6 NONE FRIABLE 23.40 30-129 C MEDUIM SAND 10 YR 5/4 NONE LOOSE 14.65 1500 GALLON SEPTIC TANK LEACHINGGALLERY DIMENSIONS AND DETAIL NOT TO TEST PIT 2 NO GROUNDWATER ENCOUNTERED USE SHOREY PRECAST 500 GALLON NOT TO USE SHOREY ST-1500-H-10 SCALE PARENT MATERIAL: PROGLACIAL OUTWASH LEACHING DRYWELL (H-10 LOADING) SCALE 3 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER CONSTRUCTION DETAIL 1 In 2590 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING DRYWELL UNIT S TAPER TON 0-8 Ap LOAMY SAND 10 YR 3/2 NONE FRIABLE 24.0 Ft. B-32 B LOAMY SAND 10 YR 4/6 NONE FRIABLE m ' 0 5 f t- 23.23 32-126 C MEDUIM SAND 10 YR 5/4 NONE LOOSE 4. m 4- O 8 In 15.40 +j L(7 GROUNDWATER ADJUSTMENT "'� 10 3.5 f t 8.5 ft 8.5 ft .5 FE EXISTING GROUNDWATER LEVEL BASED ON TOWN OF BARNSTABLE 2 4.0 ft GIS DEPARTMENT RECORDS. � + INLET CENTER COVER OUTLET END INDICATED GW MlW 500 GALLON DRYWELL INDEX WELL"- •=M1W-29 I ZONE ''A DIMENSIONS AND DETAIL 3 IN DROP READING DATE NOV. 2007 —► /� FLOW LINE Z USE H-10 UNIT FROM READING 9:. 10ir, TO 14 ADJUSTMENT INSTALL ONE INSPECTION BUILDING `: In TO RISER TO WITHIN THREE ADJUSTED GW 6.7 INCHES OF FINAL GRADE 48 in AND INDICATE LOCATION LIQUID GAS ON AS-BUILT PLAN LEVEL BAFFLE 0 33 0000 BOO! In CROSS SECTION VIEW NOTES o00c 00 C000 000°° ��C 0c 0[00 c:3 �0 1) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. I021n a 2) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). CROSS SECTION VIEW 3) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTIL.ITIEs SEWAGE DISPOSAL SYSTEM PLAN BEFORE EXCAVATING FOR SYSTEM. 2 In PEASTONE 2 in PEASTONE 4) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE. —TO SERVE EXISTING DWELLING 0 0 5) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES 28 �4,r. ro EFFECTIVE 26 MARK GRENIER AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK. In -I/2i^�^� DEPTH 1-1/2,.,GRAVEL In 6) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT 554 SCUDDER AVENUE HYANNISPORT. MA PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. � 46 in 58 in 46 In ECO-TECH ENVIRONMENTAL Z) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL 150 in E STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH INSTALLER MAY SUBSTITUTE AN APPROVED GEOTEXTILE 43 TRIANGLE CIRCLE SANDWICH MA 02563 SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING. FABRIC IN PLACE OF THE 2 in. PEASTONE LAYER SPECIFIED. ETE-2824 DECEMBER 15. 200? 212 ALL PIPE SPECIFIED ARE ATIONS -FLOW PROFILE EXPRESSEDLINV DECIMAL FEET NOT FEET ANDT INCHES.TIONS RAISE COVERS TO WITHIN SIX INCHES OF FINAL GRADE TOP OF FOUNDATION ONE INSPECTION RISER FOR LEACHING GALLERY TO WITHIN 3 INCHES OF FINAL GRADE AS INSPECTION PORT. 26.25 D-BOX MAXI SCHEDULE ALL PIPE T 0 BE PVC DROP O AND TO PITCH AT FLOW LINE I I I I 23 25 1/8 in/Ft. MIN.. 10 14' 48" sAs� PRECAST BAFFLE Y `r...., DRYWELL 7in BOTTOM OF 23.00 LEACHING LEACHING L24 - 22.60 GALLERY BASE GALLERY 6 in STONE BASE 22.77 1500 GALLON 22.50 (END VIEW) 20.50 5.00 ft + 38 ft SEPTIC TANK 17 ft. SEE DETAIL ON REVERSE o) 5 FL 12 ft ' b) 12 Ft ADJUSTED SEASONAL P 6.70 Ut a W N ~O O HIGH GROUNDWATER m� y \ mm � Na4 � 1a W N � � . 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