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HomeMy WebLinkAbout0015 SECURITY STREET - Health 15 Security Street Hyannis P A = 268 119 It E` r I0 v � o 7 o , Commonwealth of Massachusetts U11p aW H9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not tr Voluntary Assessments M, Property AddressSa le C-) r , Ow ner Ow ner s Nameinforrequired ation ie G1✓�%1 �oZ 6 0 requved for every I•m' page. Clty/Town State i 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. Impooutf When A. General information Bing out forms 5��# ��•�zZ. on the computer, use only the tab 1• Inspector key to move your cursor-do not �-� o/SIC A use the return key. Na me of Inspectordo 9� 0` Company Address 2�:aS A A VV7 t lylTown( ;V c2gD'/ / / 0 _ State [ o ZIP Code Telephone Namiber License Number B. Certification I 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 ins pection 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 16.340 of Title 5(310 16.000). The system: Passes ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority Iola 0j/ Inspect is Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpa or greater, the inspector and the system owner shall submit the report to the appropriate regional office ofthe DER 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 h ow the system will perform in the future under the same or different conditions of use. "S 't5rrs•3M3 Tile 5 Official Ins pectienFc m SubsufaceSewageDisposal SysteM. a 10,7 c , k F • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IS SecUfi S Property Address ON ner ON ner's Name information is ' required for every ArJNI f 1*1,4 ao 6 o/ % a o S page. City/Town State Zip Code Dateoftspedkion B. Certification (corn.) Inspection Summary: Check A,B,C,D or E/always com plete all of Section D A) System Passes: ;;I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. ff"not determined,"please ex0ain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or.tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): z On5.3M3 Title5OfficialInspeebonForm SubsurfaceSevmgeDisposal Symm•Page 2oft7 ;r Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form 4 Not for Voluntary Assessments IS seeuriA s}' Property Address --1/' s Xe Owner ON ner's Name �j information is /J4 �e�6.0 Ao e?o requQedforevery ar�Nl _ ==i- Page. Cityyrrbwn 47, State Zip Code Date Of Insp •tion B. Certification (corn.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(coat.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): . ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•3M3 Title50Ffidal IrspecfionForm SubsWace Sewage Disposal System-Page3017 Commonwealth of Massachusetts Title 5 Official Inspection Form IV Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /S. recur, �- Property Address z 4 Jos le(I O.v ner information CAv ner s Name �j requirdfo is / / &l i 6 0/ l0 requaed for every A✓1r1 U _ 02 0//S page. Cityrrown State Zip Code Date of Inspe tion B. Certification (cord.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis,,performed at a DEP certified laboratory,for fecal coliibrm 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 fbnn. 3. Other. r 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 ❑ ,2/ 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 a� or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow ISns-3H3 Tile 5Officiai Iris pecfianFam[Subsurface sevme Disposal System•Page 4of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IS SeC(Arl S� Property Address Ow ner O+v nees Name ,( l rquiredfore Cri?�/f �i7 �0�601 required for every page. Ckyfrown C± State Zip Code Date of lrdpecti& B. Certification (cunt.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Er"" 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. ❑ t�' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ � The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no'to each of the following, in addition to the questions in'Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes'to any question in Section E the system is considered a significant threat, or answered 'yes"in Section D above the large system has failed. The owner or operator of.any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ns-3M 3 Title 5 Official lnspeetim F oms Subsuface Savage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IS SeCuv11-f Sf Property Address O+v ner Ow ner's Name infomgtion is 1 required for every / 4i Y1 4 I Opc 6 0 0 i,S' page. Cityrrown C>C State Zip Code Date of fnspeWn C. Checklist Check if the following have been done. You must indicate"Yes"or"no"as to each of the following: Yes ❑ 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? ❑ as the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? �❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. Vo"'❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): J 30 tars•3h 3 Title 5 official Irs pectin Fartrc Sutsuface Sewage Disposal System•Page 8of 17 Commonwealth of Massachusetts Mogan=,M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments /S Secu�� S� Property Address QN ner CW nel's Name requir atifo is required for every Gi&111/ page. Qty/Town State Zip Code Date oT Insp ction _ D. System Information Description: 0�ls�/I�N l70✓� &Q Number of current residents: / Does residence have a garbage grinder? Elff Yes No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes B'No information in this report.) Laundry system inspected? ❑ Yes goo Seasonal use? ❑. Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes o Last date of occupancy: G�✓/�..• Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Gallons per day(gpd) y Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑! Yes ❑ No Y Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ 'No Water meter readings, if available: m t5i s-3M 3 Title 5 official Irs pection Form Subsuface Sewage Disposal System•Page 7 of V.P Commonwealth of Massachusetts Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /S �GGwrt -1- Property Address S ON ner Onr ners Name /��` information is 4 N 1 S / , /� V�eO� /0 oZO required for every page. Cilyfrown State Zip Code Date of Insp ctlon D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, vol ume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy 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/Altemative 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(descri be): t5ns•3H3 TilleSof ellrspectimFmnSuburfaceSewageDisposalSystem•PageSofW a. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments S406-Utet f f Roperty Address Owner Ow ner's Name rm �G s lie information is required for every Gl✓1 N I ' Q l0 OZ 0 page. Cdyrrown State Zip Code Date of hspecti6n D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: # Were sewage odors detected when arriving at the site? ❑ Yes L-90 Building Sewer(locate on site plan): ^ �i Depth below grade: feet ,✓ Material of constructi ❑ on:cast iron �PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Materia construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5irts-3M 3 Tille 5 Official Inspecfion F or[Substsface SevMe Dispose)System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form UVSubsurface Sewage Disposal System Form a Not for Voluntary Assessments /S See'u ri 6 „Sk Property Address z ON ner ON ner's Name information is 11C,&jWfLf /r/,f 0-�60/ o /! required for every page. City/Town State Zip Code Date of'lnspedWn D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or bafflel Distance from bottom of scum to bottom of outlet tee or baffle n O I�Cc How were dimensions determined? Cjv CG Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): odl Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ns•Y13 Title50Ffidal InspectianPom[SuisufaceSeviageDisposal System-Page 10d 17 y. l r Commonwealth of Massachusetts AW Title 5 Official Inspection Form UVSubsurface Sewage Disposal System Form -Not for Voluntary Assessments See'(A rs so�t Property Address S /Q Ow ner ON nets Nameinforniation is / /V equiredforev Adl Nll e I OFT �OA page. Zi frown CIState Zip Code Date dF 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, e%idence 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 worldng 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 t5rr•3M3 TiUeSOfficial ImpeedwForm Subu0ace SevMg90isposW System-Page 11 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IS Sen4vrs 417 Property Address le �p Cw ner ON ner's Name information is / �pZ-60� /0 required for every Gi✓I N If page. Cityrrown State Zip Code Date of hApection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): eo� /VV 1flo 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. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 TIBeSOfficial InspecfionFom[Subsurtaoe Sewage Disposal System-Page 12 of 17 I N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments %Vj C c,r, Property Address 1 D� e owner Ow ner's Nameinfo J on is required /7 G'✓f�J�l �0�`0� �D 4o page. Cityfrown State Zip Code Date of pection D. System Information (corn.) Type: �✓1y'l� ri„ �s ❑ leaching pits w number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativetaltemative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sh e ✓i a' i� l� /�P�h disk C� cive O S s 014 -%t* c -?4Z/J4 r 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 tSns-3h3 TiUe50f iallmpadonFormSubsrrfamSeyMeDisposalSystem•Page13of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ON ner ON nePs Name e information is ` 1 regdved for every L�/¢ 60/ page. Cdylfown State Zip Code Date i Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f.9rs•313 Tine50ffidai InspectionFortm Subsuface Se xage0ispasal Sysmm•Page 14 of 17 ' ,ef Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IS Selrwe, 4 S� Owner Property Address VS le information is ON ner's Name 011— 11t required for every A 114 0 1 1AU 41d`off /v LWO / page. C kffrmn State Zip Code We 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 manent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where p is water supply enters the building. Check one of the boxes below. hand-sketch in the area below ❑ drawing attached separately 145 f C t5ns-W 3 Title 5Official Iris pecficn F orm SulsWace Sewage Dispose)System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address s-eC44r. Owner Vr/Q information is Ow ner's Name required for every h 6� Gof(f 0,2601 page. Cityfrown State Zip Code We of nspection D. System Information (coat.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells IjoN.e- Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked wi local Board of Health-explain: �ans 4- 1S4 /rs ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must dDIU how you established the high ground water elevation: �R N/GQ !O' r !w /C�4 H c��✓sr�- 0 C e.64, . - S is �012' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3M 3 Tice 50fficial Inspeo6cn Fanrc Subsurfeoe Sewage Disposal SYMM-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments cU r, Property Address ONM ON�Name a sl rre° e u eq very _ G 0 Nf ( ' � cy,6 0 Me- Oly/rown V State Zip Cade Date Inspection E. Report Completeness Checklist lei Inspection Summary:A, B, C, D, or E checked &-<pection 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 �u6.3113 TitlWffag lmpecft Form&Aaffsoe SmageDigmd System-Page 17 d 17 4OV I� I� J � I T�l� { , I I . c� d kl� � r I S ---------Imm- I % cz- 1 JL r r� 1 1�5 -, V 0 _ E f r - _ 1 y \ ".or f� i CX s ��C, sC� s - i TOWN OF BARNSTABLE LOCATION SEWAGE # U 00 VILLAGE_414a s ''���S ,ASSESSOR'S MAP & LOT s2( k' J INSTALLER'S NAME&PHONE NO. � Q� L�'�I ^ ��1� �✓� SEPTIC TANK CAPACITY 452)0 P`fj o LEACHING FACIL=: (type) (size) 164 Y 3s 3 NO.OF BEDROOMS BUILDER OR OWNERT PERMITDATE: COMPLIANCE DATE: ZZ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility f 0 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) r Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �1.z i I� `� I jE �� �� C.n®..(� �`�� . vw 4.: �.; -� -� w W � �r.i a �..� �y�� w .r H � -�c w m � � cN - � o � �9 � No. >i Fee rwoDITIHIE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �n PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS VYJ ZippYication. for Migoar *p5tem Con!6truction i3ermit Application for a Permit to Construct Repair r pp ( ) p ( ) Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. is Sr2(vPLt{� bue-eT Owner's Name,Address,and Tel.No. AWrAmej f or jr19 �'�.4✓)rli 5 (n�vl 02(�Ot �j.fCc-u�r� S� Assessor's Map/parcel -7 7r`p" 9775 Installer's Name,Address,and Tel.No. C4pew e42 Ea t&rYeSt) U-C Designer's Name,Address and Tel.No. f?d.t?-c 7(.3 C—v.c(e C's� �tee�::zg W0(2r-g SO$ if 2z q0 7-9 rc-K—977-S 3 t)r Type of Building: Dwelling No.of Bedrooms 3 Lot Size 9?( t4 t sq. ft. Garbage Grinder ( ) Other Type of Building S'i No.of Persons Ll Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) <3 O gpd Design flow provided y 4 gpd Plan Date Y`L�L�— 2 op'�, Number of sheets Revision Date Title _ i Se.c,a(� Size of Septic Tank i �sD7 A, Type of S.A.S. TiemL Description of Soil 5�0 _c_ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o Ith. Signed q Date0'07 Application Approved by Date if 7 Application Disapproved by: Date for the following reasons Permit No. Date Issued r No. e E * ,�' Fee �! Entered in computer: VYe, : THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS4" V g1 q ~ ZippYication for Migo�al *p�tem Construction Permit ,s,..',• Application for a Permit to Construct( `j Repair O Upgrade!( Abandon O ��Complete System ❑Individual Components Location Address or Lot No. IS 5 L'Lv2 S ,� Cee Owner's Name,Address,and Tel.No. Ajnr q.je1 1jgOt}T q Assessor's Map/parcel q 11 -7 76 7A b 41 J��".j 41el Installer's Name,Addr s,and Tel.No. e4,af�.<ti' +~A f�/P�>cy (c Designer's Name,Address and Tel.No. ^ P2v,c>,,c ��3 C-v<Je C"r�yi�teev"4 c.,/o9K5 w. Gi F Tab-47 - S 3�3 T �., . Type of Building: GG Dwelling No.of Bedrooms Lot Size O� �^{ t sq.ft. Garbage Grinder ( ) Other Type of Building 'S; No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) O gpd Design flow provided 73 4 S gpd Plan Date I )1-2I-IQg' Number of sheets 1 Revision Date � Title 1 S St.vC Size of Septic Tank 1'stl.0 C�A Type of S.A.S. J1 A�✓440/L -T7e ?C..L Description of Soil Nature of Repairs or Alterations(Answer when applicable) ftj (jam C,/1 TA4it% >k. �r 1�,1n t 1A fi Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to lace the system in o eration until a Certificate of P P Y P Compliance has been issued by this Board o eFERe lth. ' Signed .s O� Date g Application Approved by / v Date Application'Disapproved by: Date for the following reasons Permit No. Date Issued r- THE CO ONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded K) } Abandoned( )by ✓,fie at [ r(� �-* t h T 5 , has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. /" dated Installer rjanz,�I', E if ltel f i*S-f S �•`-L- Designer 2u di, WAve #bedrooms �_ Approved design flow gpd The issuance of this permit shall n t b c sled as a guarantee that the sys m wi u t'o as designed.. Date / Inspect r �-- ----------------------------- No. Fee / i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS =i5po5al,,p!6tem Con5tructton Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ) Abandon ( ) System located at 1 S S Q.L VVtJ�4 S COLT 14, ►/��1't and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or,special conditions. Provided: Construction/ust a com leted within three years of the date of thi 1 Date Approved by i Town of Barnstable ,Regulatory Services Thomas IF, Geller, Director Public Health Division Thomas McKean,Director 200 Main Street,Hyena*MA 02601 Ofrice 508-862-4644 Fran: 508-740-6304 � er werti4i�>�tia► Date: .U k7 Sewage Permit# ?eur_- d c°t .assessor's Map\Parcel 2� Desigu*r: t�2� ✓12C�r,�-e a ems' Installer: Addresst Address; i 11z. MA On - t` l ' ZQa? _ ��rcc�-�_ ��ee��1 c e,was issued a permit to install a (elate) �-' (installer) la y 1 S Se �ci based can a design drawn byse tics stern at.,�____ (address) dated _ 1 Z 1 Zot to �-.. .�d designe>r) T certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as .lateral relocation of the distribution box and/or septic tank. i certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of aly component of the septic syxterra) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. PETER T. \� r a McE4aTEE :l a tattler's Sigh O - ! CIVI No.35109 �pc� (Designer's Signature) (Affix Designer's Stamp Here) ®se.NLW Q� Hea1!WSepsic/Nsiper Cernfiratinn Fort 3-26-04.dm � zI4S COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �.y see - . . . MAP 4 2003 PARCEL i I AUG 1 LOT .Tow �T. TITLE 5 r�taLrr+of OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. Owner's Name: Owner's Address: Date of Inspection: Name of Inspector: lease p int) rJt7 ' `"l Company Name: Mailing Address: oz)�ey�r Telephone Number: `09—'7-7/ • Q --'S�� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and.complete as of.the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: +/ Passes Conditionally Passes eeds.Further Evaluation by the Local Approving AuthorityL . ails Inspector's Signature: / Date: cg' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 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 I Page 2 of I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ' Property Address: Owner: Date of Inspection: .'Ja Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: l✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 1.5.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the - for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection.if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of;sewage,backup or break out or high-static water level in-,the distribution`boxdue to broken or obstructed pipe(s)or due to a broken;settled or.uneven distribution box. System will pass inspection if(with approval of Board of Health): broken.pipe(s)are replaced obstruction is removed distribution box is leveled or-replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: . 2 I/ 1 Page 3 of 1'l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address: GA?," 7 1 Owner: " Date of Inspection C. Further Evaluation is Required by the Board of Health: Conditions.exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety, or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b).that the system.is not functioning in a manner which.will'protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a,manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS.and the SAS is within 50 feet of a private.water supply well. _ The system has a septic tank and.SAS and the SAS is less than 100,feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A•copy of the analysis must be attached to this form. Provided, 3. Other:. 3. Page 4 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: OwnerA,2&j f 1, Y'ln".ho Vj) eofi-n-"spec—tion—/"4L"441,Q2�ZZOOCG OO vol U D. System Failure Criteria applicable to all systems: each of the folio-wing for all inspections: You must indicate"yes"or"no"to Yes No Backup of sewage into facility or system component-due-to overloaded or clogged SAS"or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool V Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or J cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. �J Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water supply. _ U Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within.50.feet of a private water supply well. Any portion ofa cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen,is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) NO (Yes/No)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 correctthe 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 I5,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to.the criteria above) yes no — the system is within 400 feet of a surface drinking water supply the system is within 200 feet of.a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a signif cant threat or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'B;:..; , CHECKLIST. Property Address: n i Owner: 9 Date of Inspection• p Check if the following have been done. You must indicate"yes" or."no"as to each of the following: _ Yes o t 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? V Were as built plans of the system obtained and examined?(If they were not available note as N/A) V _ Was the facility or dwelling inspected for signs of sewage back up V _ Was the site inspected for signs.of break out? V _ 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 7 baffles or tees, material of constr uction, dimensions,depth of.liquid,depth,of sludge and depth of scum??_ Was.the facility owner(and occupants if different from owne.0,pro.vided with.infonnation on the proper maintenance of subsurface sewage disposal systems ? The.size and location of the Soil Absorption Systenr(SAS)on the site.has been determined based on: Yes no _ /_t/Existing information. For example, a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Pail C.is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 f � Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE WAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 15, a Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): . Number of.bedrooms(actual): �j.. DESIGN flow based on 31 O.CMR 15.203 (for example: 11:0 gpd x 9 of bedrooms): ` Number of current residents: Does residence.have.a garbage grinder(yes or no - Is laundry on a separate sewage system (yes or-no yes separate inspection required] Laundry system inspected(yes or no — Seasonal use: (yes or no): Water meter readings, ' available(last 2 years usage(gpd)): 01—`!L490 Sump pump(yes or no . Last date of occup COMMERCINUINDUSTRIA Type of establishment: Design flow{based on 310 CMR,.15.203.): gpa Basis of design-flow(seats/person's/sgft,etc:): . :. Grease trap,present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available:- Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: L Was system.pumped as part ofthe (Y inspection es.or no : P ) If yes, volume pumped: gallons--How was quantity pumped determined? _ Reason'for_pump ing: . TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy —Shared system.(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight.tank` —Attach a copy'of the DEP.approval Other'(describe): Q/ Approximate age of all components,date installed (if known)and source of information: Weresewage odors-detected when arriving.at the site(yes or no) 6 a Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: BUILDING SEWER(locate on site pla Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain):- Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of ieakage,etc.): SEPTIC TANK: locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no): _(attach a.copy of certificate) Dimensions: Sludge depth: .Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee.or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were.dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP/(locate.on.site plan) Depth below grade:Material of constructio- n:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Continents(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related 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) Property Address: ` �� Y n . Owner. Date of Inspection: 3 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION-BOX: - (if present must be opened)(locate,on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): ` PUMP CHAMBER: ' (locate on site plan) Pumps in'working order(yes or no): Alarms in working order(yes or no): Comments note condition of'um clia'iiiber conditior of`um sand appurtenances,etc:' ( P P P P PP )R Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: ,Q Owner: Date of Inspection M SOIL ABSORP ION SYSTEM (SAS): locate on site plan, excavation not required) If SAS not located.explain why: Type leaching,pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches, number, length: beaching fields,number, dimensions: i/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, tc.): A J CESSPOOLS: (cesspool must be pumped as part of inspect ion)(]ocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: y/' Depth of solids layer: Depth of scum.layer: Dimensions of cesspool:_ Materials of construction: Indication of groundwater inflow(yes or no omments(note condit'.-n of soil;signs o ydrauli failure, leve of pondin- conditio ,of vegetation,etc.): , PRIVY. 'locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: \/ Owne Date of Inspection: G� 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. i 4 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: h 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 hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: I� 11 F Permit Number: �y Date: Completed by: ll�� HIGH GROUND-WATER LEVEL COMPUTATION Site Location: Lot No. " Owner: Address: y— Contractor:- t�� Address: S �L t' • . Wrote$: /1S STEP 1 Measure depth to water table tonearest 1/10 ft. ........................................................................... .... .Date month/day/year _ 1 STEP 2 Using Water-Level Range Zone _ and.'lndex Wel'I'Map locate site and determine: ZI A Appropriate index well..................................... ��. , 1. O Water-level range zone .................................................. S T EP 3 Using monthly report."Current I I" Water Resources Conditions" 1. • I determine current depth to l water level for index well .......::............ � " month/year STEP L'. using Table of.Water-level Adjustments for index well (STEP 2A), current depth to Water level for index.vvell (STEP 3)., and water-level zone (STEP 2B) 12 i 15 determine water-level adjustment............................:.............................................................. STEP 5 . "Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from"me•asured'de'pth to water I �. levelat site (STEP 1) .................................................._............................................................. 11,5; J Figure 13.--Reproducible computation Tor m. v�.� � .. � } �. F •� F j ' y ') .A _ P =� � !: { '�� ' '" �.� F .',r, r, 1` n� .<.. s 1�--��' F ei. ' �}f},3 i 1 k f 1 P '° f �� 6l . � t , d t � i� t! ' ;T iE j�' is �# i � -� i' 3 � � F i .1 {� S t .. I �� �� } + �; _ �:�`+ { .. � i ��� i ' �� � � � tj P. \�\V. M N{ ��� �� S'"„e. / COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION A j Z A f W ' d !f t F K I� Je V� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 15 SECURITY ST HYANNIS,MA 02601 Owner's Name: EMMETT WHITE Owner's Address: 39 KNOWLES RD WORCESTER MA 01602 Date of Inspection: 5/29/01 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS RECEIVED Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 JUN 15 2001 CERTIFICATION STATEMENT TOWN OF BARNSTABLE HEALTH D I certify that I have personally inspected the sewage disposal system at this address and that the s true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Passes _ Ne4Flhervaluation by the Local Approving Authority Fa Inspector's Signature: Date: 5/29/01 a The system inspector shall suf 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 now of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ****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 Inrnrrtinn Form (/15!)noll r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15 SECURITY ST HYANNIS,MA 02601 Owner: EMMETT WHITE Date of Inspection: 5/29/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: _ One or more system components as'described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined".please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 15 SECURITY ST HYANNIS,MA 02601 Owner: EMMETT WHITE Date of Inspection: 5/29/01 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank'and SAS and the SAS is within 50 feet of a private water supply well. _ 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 15 SECURITY ST HYANNIS, MA 02601 Owner: EMMETT WHITE Date of Inspection: 5/29/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Wa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 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.] _ (Yes/No)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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. �t r� Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 15 SECURITY ST HYANNIS,MA 02601 Owner: EMMETT WHITE Date of Inspection: 5/29/01 Check if the following have been done. You must indicate "yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X Has the system received normal flows in the previous two week period X Have large volumes of water been introduced to the system recently or as part of this inspection ? _ X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site'? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? rl The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ X Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) i 4 - Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 15 SECURITY ST HYANNIS,MA 02601 Owner: EMMETT WHITE Date of Inspection: 5/29/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): YES Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CM 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X 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): n/a Approximate age of all components,date installed(if known)and source of information: 1969 Were sewage odors detected when arriving at the site(yes or no): NO 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: 15 SECURITY ST HYANNIS,MA 02601 Owner: EMMETT WHITE Date of Inspection: 5/29/01 BUILDING SEWER(locate on site plan) Depth below grade: 24" Materials of construction: Xcast iron _40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: (locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 5' X 5' BLOCK CESSPOOL" Sludge depth: n/a Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a 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.): MAIN CESSPOOLS AND ALL COMPONENTS APPEAR TO BE STURCTURALLY SOUND.RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.THE CESSPOOL WAS EMPTY AT THE TIME OF THE INSPECTION.HAS BEEN HALF FULL' GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a t` 7 I— Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 SECURITY ST HYANNIS, MA 02601 Owner: EMMETT WHITE Date of Inspection: 5/29/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): n/a PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no):'NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): n/a Q Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 SECURITY ST HYANNIS,MA 02601 Owner: EMMETT WHITE Date of Inspection: 5/29/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a 5' X 5' BLOCK CESSPOOL overflow cesspool, number: n/a r innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs-of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE OVERLFOW PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAS BEEN HALF FULL CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Page 10 of 11 F OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 SECURITY ST HYANNIS,MA 02601 Owner: EMMETT WHITE Date of Inspection: 5/29/01 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. A A U �� as AP, 3q 1t in Page 11 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 SECURITY ST HYANNIS,MA 02601 Owner: EMMETT WHITE Date of Inspection: 5/29/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: z, NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Security Street Property Address White /' b\/ Owner Owner's Na pie information is required for Hyannis MA 02601 02/01/2012 every page. Cityr town State zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important., When filling out A. General Information formsthe computer, r,use 1. Inspector: only the tab key to move your A.Riker cursor-do not Name of Inspector use the return key. R.L.C. Company Name P.O. BOX 726 Company Address SOUTH YARMOUTH MA 02664 '00A City/Town State Zip Code 508-776-6460 S14590 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this add ss and thoj3he <D information reported below is true, accurate and complete as of the time of the inspection. Thy insertion was performed based on my training and experience in the proper function and i intenance�.. f oncsite sewage disposal systems. I am a DEP approved system inspector pursuant'to,Section 15 340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Uj rn p. 02/02/2012 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. i� t5ins•11/10 Title 5 Official Inspectioad ce Sewage Disposal System•Pege 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 15 Security Street Property Address White Owner Owners Name requinform r on is Hyannis MA 02601 02/01/2012 requiredd for Y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Sptic tank ,distribution box and area of S.A.S. were inspected and no obvious indication of failure was observed. Riser was added to distribution box that was 20" deep to cover brought to 6" grade. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by' the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Security Street Property Address White Owner Owner's Name information is required for Hyannis MA 02601 02/01/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 15 Security Street Property Address White Owner Owner's Name information is required for Hyannis MA 02601 02/01/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Security Street Property Address White Owner Owner's Name information is required for Hyannis MA 02601 02/01/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Officia-1 Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 15 Security Street Property Address White Owner Owners Name information is required for Hyannis MA 02601 02/01/2012 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C.is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information -Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 15 Security Street Property Address White Owner Owner's Name information is required for Hyannis MA 02601 02/01/2012 _ every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: System was Issued C.O.0 on 01/09/2007 for installation of 1500 gallon septic tank ,distribution box and 5 Hi-Cap Infiltrators. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2011=134GPD g ( y g (gp ))' 2010=103 GPD Detail: Barnstable Water Dept. provided water meter reads Sump pump? ❑ Yes ® No Last date of occupancy: LINK. Seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 15 Security Street Property Address White Owner Owner's Name information is required for Hyannis MA 02601 02/01/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Barnstable Sewage plant Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Not required Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 15 Security Street Property Address White Owner Owner's Name information is Y required for Hyannis MA 02601 02/01/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Installed in Jan.2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Interior plumbing had no indication of leakage or staining Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gallon precast concrete tank with ADS risers on inlet and outlet covers If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'6"x5'8"x5'8" Sludge depth: 6" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Security Street Property Address White Owner Owner's Name information is required for Hyannis MA 02601 02/01/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness <1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PVC TeeY's in place with gas baffle on outlet,no indication of leakage Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Security Street Property Address White Owner Owner's Name information is required for Hyannis MA 02601 02101/2012 every page. CityfTown 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Security Street Property Address White Owner Owners Name information is required for Hyannis MA 02601 02/01/2012 every page. Citylrown 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 at single outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No indication of high water staining or carryover observed at distribution box. Cover was 20"deep and riser was installed to raise cover to 6"of grade. 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.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11110 Trfie 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Security Street Property Address White Owner Owner's Name information is required for Hyannis MA 02601 02/01/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5x HiCapInfiltrator w/stone ❑ 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.): Soils above chambers dry and free of effluent staining or presence no indication of failure observed in area of S.A.S. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Security Street Property Address White Owner Owner's Name information is required for Hyannis MA 02601 02/01/2012 every page. Cityrrown 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.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 15 Security Street Property Address White Owner Owner's Name information is required for Hyannis MA 02601 02/01/2012 ' every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below El drawing attached separately S lee 4 // / 49�PJ•,J o �" )y��y i o } 1 3 U 5 3� 1 LU `so® O A e6G r r b w t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Security Street Property Address White Owner Owners Name information is required for Hyannis MA 02601 02/01/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >12feet 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: 12/29/2006 Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Deep hole and soil log on file performed on 12/28/2006 witness by Board of Health ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Soil log on file with engineered plan with approved design elevations with 5' seperation to bottom of test hole. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-I WO Tide 5 Official Inspection form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Security Street Property Address White Owner Owner's Name information is required for Hyannis MA 02601 02/01/2012 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN.OF BARNSTABLE LOCATION TOWN. Ce MLAGE SEWAGE ASSESSOR'S MAP & LOT : IIVSTALLER'S NAME a PHONE ' NO. SEPITC TA NK CAPACITY YUr� LEACHING FACILTIy: NO. OF BEDROOMS (size)—Z'-',y y — s BUILDER OR OWNER A�GOMPLLANCE PERMTTDATE DATE: Separation.Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leachin Facilit Private Water Supply Well and Leaching,Facility i' y ✓ Feet on site or within 200 feet of leaching facility] any wells exist Edge of Wetland and Leaching Facility �-- within 3 (zany wetlands exist Feet 00 feet of leaching facility) Furnished by ---- Feet j i i 33 : 1 i a . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 15 Security St. Property Address Natanael Baptista Owner Owner's Name information is required for Hyannis Ma. 02601 1/30/2009 every page. City/Town State Zip Code Date of Inspection Inspection.results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms the I r��� compute r,use 1. Inspector: 4t.f/J') only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved,system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1/30/2009 Inspector's Signat a Date f The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater;the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurfablew p e age Disposal System•Page 1 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 15 Security St. M Property Address Natanael Baptista Owner Owner's Name information is required for Hyannis Ma. 02601. 1/30/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or,repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 15 Security St. Property Address Natanael Baptista Owner Owner's Name information is required for Hyannis Ma. 02601 1/30/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑. ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with.approval of the Board of Health): ❑ broken pipe(s) are replaced. ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N. ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet.of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 15 Security St. 7M Property Address Natanael Baptista Owner Owner's Name information is H annis Ma. 02601 1/30/2009 required for y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply, ❑ The system has a septic tank and SAS and the SAS is within 50 feet of'a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool •❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Security St. Property Address Natanael Baptista Owner Owner's Name information is required for Hyannis Ma. 02601 1/30/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ N Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone Il'of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 15 Security St. Property Address Natanael Baptista Owner Owner's Name information is required for Hyannis Ma. 02601 1/30/2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following:. Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ®, Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Z. ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR.15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cwM 15 Security St. Property Address Natanael Baptista Owner Owner's Name information is required for Hyannis Ma. 02601 1/30/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1500 gallon septic tank,distribution box and 5-infiltrators. Number of current residents: Does residence have a garbage grinder? ❑. Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2007:97,000 9 ( Y 9 (gpd)): 2008:34,000 Detail 2007: 93 gpd. 2008: 266 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: unknownDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): , , Grease trap present? ❑ Yes ❑ No. I� Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 15 Security St. Property Address Natanael Baptista Owner Owner's Name information is required for Hyannis Ma. 02601 1/30/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of.occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 15 Security St. Property Address Natanael Baptista Owner Owner's Name information is required for Hyannis Ma. 02601 1/30/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System installed 1/09/2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.):. Joints appear tight.No evidence of Ieakage.System vented through the house vents., Septic Tank (locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: . years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 4" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 15 Security St. Property Address Natanael Baptista Owner Owner's Name information is required for Hyannis Ma. 02601 1/30/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" 6., Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12i' 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.): Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts U W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ° 15 Security St. M Property Address Natanael Baptista Owner Owner's Name information is Hyannis Ma. 02601 1/30/2009 required for y every page. City/Town State Zip Code, Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 El polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design.Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 15 Security St. Property Address Natanael Baptista Owner Owner's Name information is required for Hyannis Ma. 02601 1/30/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.); Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Security St. M Property Address Natanael Baptista Owner Owner's Name information is required for Hyannis Ma. 02601 1/30/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5-Infiltrators ❑ 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.): Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 15 Security St. Property Address Natanael Baptista Owner Owner's Name information is required for Hyannis Ma. 02601 1/30/2009 every page. City/Town 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.): Privy(locate on site plan): Materials of construction: — Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14 I - Map t Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Ma p ®Size Zoom Out ,� In AK 4a 1 :taa5t?e 32w N ,16 r . , �t h II 5 .rr II � - ' � 3 r� rp F�• y :Ily +r r NOR R, ik II ' 'I — , It • - a a _ II e r • y " li Va 0 2O Feet ti Set Scale 1 r 20 I Aerial Photos I MAP DISCLAIMER YAr (`nnvrinh4 9f1l1 F_9MA Tn,.m M Rome4ohln hAA All rinhhe--l' http://www.town.bafnstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=268119&mapp... 2/2/2009 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Security St. Property Address Natanael Baptista Owner Owner's Name information is required for Hyannis Ma. 02601 1/30/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 15' 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: 12/29/2006 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data. USED:Technical Bulletin 92-000-01 Plate#2 annual ranges of groundwater elevations. ;Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 15 Security St. G M SV a y Property Address Natanael Baptista Owner Owner's Name information is Hyannis Ma. .02601 1/30/2009 required for y every page. City/Town. 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 Z. System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Fee ONWEALTH OFMASSACHUSETTS Na. M TTS ' / E COM HUSE - THE SSAC PUBLIC HEALTH DIVISION -BARNSTABLE,MA aY, stein construction Permcct 3Bi5pa V de ) Abandon ( ) Permission is hereby granted to Construct ( ) Repair ( ) . Upgrade System located at osal System Construction Permit.The applicant recognizes his/her duty and as described in the above Application for D1sp .Yspecial or to comply with Title 5 and the following local prnvi three s f the datelolf th` Provided: Construction ust e co leted within th years Approved by . Date �v�vJ MHt' N.T.S. 160 GENERAL NOTES: 1, ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO-THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO DESIGNPENGIINEER AND APPROVAL BY THE BOARD OF HEALTH AND THE 4, ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM, 6, THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR. THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE, S. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 150' OF THE S.A.S. 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO. BEGINNING CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE AREA BENEATH AND .FOR 5 FT. ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). o PETER T. M CIVIL EE N PROPOSED SEPTIC SYSTEM UPGRADE No. 35109 15 SECURITY STREET, HYANNIS, MA fC1STE � Prepared for: Natanael Baptista, 15 Security Street, Hyannis, MA 02601 10 E� Engineering by: Surveying by: SCALE DRAWN JOB. NO. EngineedngWorks HOOD SURVEY GROUP 1"=20' P.T.M. 257-06 i 12 West Crossfield Road P.O. Box 1724 Forestdaie, MA 02644 Moshpee, MA 02649 DATE CHECKED SHEET NO. (508) 477-5313 (508) 539-7799 12/29/06 P.T.M. 1 Of 2 r _ THE COMMONWEALTH OF MASSACHUSETTS' BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site S.wage Disposal System Constructed ( ) Repaired ( ) Upgraded ) Abapdoned( )by 1J.CL gitkc ov' e L L• �- at f, �� Sic j eQ,il has een cons ct d in ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer t •. ' C`-( .. Designer e °1 —7 � e12 #bedrooms Approved design flow gpd The issuance of this permit shall n tt bb c nstr,}aed as a guarantee that the sys w o designed. Date / / `/ Inspec r a Town of Barnstable Regulatory Services >l Thomas 1F',(IkUer, Director NAM Public Health Division Thomas McKean,Director 200 Main Strett,Hyss als,.%IA 02601. Off-icc� 508-862.4644 - Fax: 508-740-6304 Date: �� 7 Sewage Pertnit# '� 0°g Assessor's MaptParcel �6 E ll� Des#gnsr: reA, r► c:C,4-a e C Installer: G L��C� G✓��f��;ti,S�j Address; Address: J ,G'� ��13 777 3 ut-N'-5 y .cti On_ -fie �c,-��'"��z"("r��{�was issued a permit to install a (date) i.installer) , septic system at _f` c,sn _ based on a design drawn by (address) d designer)) I certify-that the septic system referenced above was installed sub'stantiall according to the design, which may include minor approved changes such as Lateral relocation of the distribution box and/or septic tank. - l certify that the septic system referenced above was installed with major changes (i.e. greater than 14' lateral relocation of the SAS or any vertical relocation of any component of the septic. system) but in accordance with State& Locat'Regulations. Plan revision or certified as-built by designer to follow. PE!Eli T. ze, 6 a taller s sigtta e) csv,L �> No.35100 F' / (Designer's Signature) (Affix Designer's Stamp Here) COMPLIANCE WILL NOT (} H"1th/SepticMvsiper Certification Form.3-26-04.doe i Town of 1B4' rnstable P# of Department of.Regnlatory Services • Public Health Division Date ' Matx " 200 Main Street,Hyannis MA 02601 ibsa s$ ' AffO M11'I� , >9 4 Ar ed Time Date Schedul Fee Pd. i ,Foil Suitability Assessthent for age lis�al Performed By: Witnessed tBy LOCATION& GENERAL INFORMATION Owner's Name N a*—q,n 0lt_ Location Address'. 15 S.e Gu r Address S q 0 -e. (` Q Engineer's Name(9f�r- mC Ch i P� Assessor's Map/Patcel: 2(Q b -- k -\ vim S�j NEW CONSTTR�RU&ION REPAIR X i Telephone# S Q A!� Land Use I�2.S`�`��nd�� Slopes(4o) '� Surface Stones Distances from: Open Water Body ft Possible Wet Area?�—ft Drinking Water Well I ft C>r7 _ft Other ft ))rainage Way ft Property Line SKETCH:(street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 6h t ko 44C_CIOA Qi C W��S� Depth to Bedrock Parent material(geologic) i J i Weeping from Pit Face Depth to Groundwater Standing Water in Hole: �/ I . ------ -- Estimated Seasonal:High Groundwater ­;> I'20 ATION FOR SEASONAL HIGH WATER TABLED�T'ERNIIN Method Used: I N` la. ___io. Depth t0 still DI©Ides: ft. Depth Observed standing in obs.hole: in. groundwater Adjustment Depth toiweeping from side of obs.hole: Adj {actor, _ Adj.Groundwater level Index Well# Reading Date: Index Well level - PERCOLATION TESL' Date 1 Z 20 Tirue 11 . Observation ( Time at 9" -- -------�-- Hole# 0 Time at 6" Depth of Perc s 'rime(9"-6") ._I Start Pre-soak Time.C �— � -qo 2'I �p���(JdiS HZ0 End Pre-soak �1 c h9S Rate Min./Inch C 2 1 Additional Testing Needed(Y/N) Site Suitability Assessment: Site Passed Site Failed; Observation Hole Data To Be Completed on Back Original: Public Heith Division --------- ercola'ion test is to be conducted within 100' of wetland,you must first notify the ***If p � Barnstable 6-4servation Division at least one(1)we6k prior to beginning. "DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture .Soil Color Soil ! Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. C nsistenc ravel o 0 A fit. 1:oq6/, ya -1 zo c - � C L___T DEEP OBSERVATION HOLE LOG. Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel A sL 1_a YlZ 313 P- v DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Gravel 'DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structurc,Stones,Boulders. Consistenc ra el Flood Insurange Rate Mau: Above 5160 year flood boundary No— Yes Within 100 year boundary No__N, Yes Within 100 year flood boundary No Yes Depth of Natutaffy Occurring Pervious Material Does at least fo r feet of naturally occurring pervious material exist in all areas observed throughout the area proposed fbr the soil absorption system? If not,what is the depth of naturally occurring perNhous material? Certification I certify that on O.5 (date)I have passed the soil evaluator examination approved by the Department of l nvironmental Protection and that the above analysis was performed by rrtie consistent with . the required ing,expertise and experience described in 310 CMR 15.017. Signature Date ®So Q:SEPTICVERCMRM.DOC ' LEGEND E WEST MAIN ST _e 197.PO 123_ �g PROPOSED CONTOUR 79 PROPOSED SPOT GRADE No�eP 9 �_„�,,;,/' EXISTING CONTOUR r Xtn x_.95,46` _ N08004130"E TEST PIT Q. ... �µ A.921 N Tx 96.66 Su9 h to °c TPA-2 _3_5._3' T 2 W EXISTING WATER SVC. g„ LOCUS rR OPOSEG EXISTING GAS SVC. dCraigaie Beach Rd5rnith St 10' . . D—BOXpWtt-- EXISTING OVERHEAD WIRES EX19T1NG CE55POOL9 �TO 6E PUMPED AND — _ -: 0 _0-twomum W"SAND a $ BENCHMARK LOCUS MAP N.T.S. 9EWERCONNECTION r �, L.....-�.--�----- - e� OPROP.INV.-98.5t(VERIf-Y) e � / . SEPTIC i ..." 3 _. TANK PROVIDE CLEANOUT — 1 BENCHMARK: x..__99,..8.2 CORNER fof CONC. PATIO ELEVATION — 100.0' _...... i I i (ASSUMED DATUM) 4 r°CIO ` _ o GENERAL NOTES: }M C) c 99,S5 jn 0 �a / � �O 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL lA > SEWER OUTLET BOARD OF HEALTH AND THE DESIGN ENGINEER. ° INV.=99.25 j W V,j co / // 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS [ / OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE Z I 15TY jj`/% U' I LOCAL RULES AND REGULATIONS. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR , / . FR1VI' + TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE / T.O.P. 102.421, / II DESIGN ENGINEER. '9101.92 n 00,82 i 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 100.79 �. ( ENGINEER SHOWN HEREON SHALL N REPORTED TO THE DESIGN NEER BEFORECONSRUUCTIONCO CONTINUES. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. ~� 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF APN 268- I i 9 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 1 8,814±5P I 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 150' OF THE S.A.S. y 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED TO A CONDITION BETWEEN OWNER AND CONTRACTOR. A h G REED UPON �0 75.07� �9 _ I 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 504°33'ZO'M/ �,�� "'' THE LOCATION CONSTRUCTION,OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. 100 EO PAVEMENT 4 AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). E7 2 �� � OF �A�SgCy o PETER T. SECURITY STREET MCI�ILEE NEngineeringWorAs PROPOSED SEPTIC SYSTEM UPGRADE No. 35109 15 SECURITY STREET, HYANNIS, MA A R£CISjE��� �`� for: Natanael Baptista, 1.5 Security Street, Hyannis, MA 02601 G 10 by: Surveying by: SCALE DRAWN JOB. NO. ng Works HOOD SURVEY GROUP 1"=20' P.T.M. 257-06 ssfield Road P.O. Box 1724 MA 02644 Mashpee, MA 02649 DATE CHECKED SHEET N0. 5313 (508) 539-7799 12/29/06 P.T.M. 1 Of 2 i { NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL.94.3 - � ELEV. TOP ; FOR A DISTANCE OF 15' AROUND THE FOUNDATION I FINISH GRADE: 96,2-97.3(MAX.) PERIMETER OF THE S.A.S. (Existing) EXISTING F.G. EL.98.0t F.G. EL.97.2t F­ 4 MAX. COVER OVER S.A.S. = 36" MAINTAIN 2% MIN SLOPE OVER LEACHING AREA " SCH 40 PVC PERFORATED PIPE WITH SCREW CAP SET TO WITHIN 3" OF FINISH GRADE TO SERVE AS INSPECTION PORT. L — 13' L — 8 A 4" SCH 40 PVC L =4' - 6" 3„ 4" SCH 40 PVC } 4" SCH 40 PVC a ® S= 2% (MIN.) _ 10" 14" S= 1% (MIN.) 6' C� S= 1% (MIN.) 11" EFF. PROPOSED DEPTH e: 1500 GALLON INV.EL=95.75 INV. EL.=95.00 t ti...p... SEPTIC TANK GAS INV. EL.=95.17 fl INV.ELEV.=93.80 2' 5 UNITS AT 6.25'/UNIT = 31.25' 2' BAFFLE { INV.EL=96.00 EFFECTIVE LENGTH = 35.3' INSTALL INLET & OUTLET TEES GAS BAFFLE TO BE INSTALLED ON USE 1 ROW OF 5-HIGH CAPACITY INFILTRATOR CHAMBERS (H-20) TIE IN TO SEWER J OUTLET TEE AS MANUFACTURED BY IN SERIES SURROUNDED W/STONE TO FOR A 10.8' X 35.3' S.A.S. OUTSIDE PATIO-ADD CLEANOUT TUF-TITE, ZABEL, OR EQUAL INV.=98.50t(VERIFY) NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING I SOIL ABSORPTION SYSTEM (PROFILE) PIPE INVERTS PRIOR TO CONSTRUCTION. I N.T.S. 2) SEPTIC TANK AND D-BOX-SHALL BE SET LEVEL AND TRUE TO GRADE ON A MECHANICALLY COMPACTED 2" LAYER OF SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN ( 1/8"-1/2" DOUBLE 310 CMR 15.221(2). BREAKOUT ELEV.=94.3 — WASHED STONE 3) INSTALL INLET & OUTLET TEES AS REQUIRED. INV.ELEV.=93.80 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE BOTTOM ELEV.=92.88 3/4"-1 1/2" DOUBLE AS MANUFACTURED BY TUF—TITE, ZABEL OR EQUAL. 4' 2 8' 4 WASHED STONE (3) 5" DIA.OUTLETS 16' I 5' MIN. ABOVE BOTTOM OF EFF.WIDTH=10.8' 15.5" _� ----��2" T.P. EXCAVATION OR G.W. SEPTIC SYSTEM PROFILE NO G.W. EL: 86.4 15.5" O 12" SOIL ABSORPTION SYSTEM (~SECTION) g• 8" N.T.S. 2" I D-BOX DESIGN CRITERIA I NUMBER OF BEDROOMS: 3 BEDROOMS SOIL LOG SOIL TEXTURAL CLASS: CLASS I DESIGN PERCOLATION RATE: <5 MIN/IN O ) DATE: DECEMBER 28, 2006 (P-11,556) DAILY FLOW: 330 G.P.D. a I OPOSED S.A.S. I SOIL EVALUATOR: PETER T. MCENTEE P-E. DESIGN FLOW: 330 G.P.D. p 0 o a o 0 0 0 0 0 0 0 I WITNESS: DONALD DESMARAIS - HEALTH AGENT GARBAGE GRINDER: NO PROPOSED SEPTIC TANK: 1500 GAL. CAPACITY 00000000 00000000 � '8„� 6'j lb, El, I TP- 1 <d Depth Elev. TP-2 pepth LEACHING AREA REQUIRED: (330) = 445.9 S.F. f---- 28" �, 96.8 q 0" 96.4 A 0.. .74 Closed End Plate Open _End Plate un SANDY LOAM SANDY LOAM USE 1 ROW OF 5 HIGH CAPACITY INFILTRATOR UNITS W/STONE. Q 10YR 3/3 10YR 3/3 LID 95.8 B 12". 95 7 B 81, AS SHOWN FOR AN SAS HAVING THE DIMENSIONS: 35.3 x 10.8 6 SANDY LOAM SANDY LOAM SIDEWALL AREA: 2(10.8'+35.3') x 0.92' = 84.8 S.F. tK �9. ^ 10YR 5/8 10YR S/8 - - — 2 93 8 ' - - 36" 93.9 BOTTOM AREA: 35.3' x 10.8' = 381.2 S.F. C C. 30 TOTAL AREA: 466.0 S.F. gm77"1 76', gg> DESIGN FLOW PROVIDED: 0.74(466.0 S.F.) = 344.8 G.P.D. r -II------ 75"-- ---� I----34"— -f"3 TIO f n D a 70,. PROPOSED SEPTIC SYSTEM UPGRADE 1.25 SEWER OUT T fM—CSAND M—CSAND 15 SECURITY STREET, HYANNIS, MA Side View End View � + 2.5Y 6/4 2.5Y 6/4 INV.=99.25 HIGH CAPACITY INFILTRATORS, H-20 LOADING Ff Prepared for: Natanael Baptista, 15 Security Street, Hyannis, MA 02601 INFILTRATOR CHAMBERS � � � , � Engineering by: Surveying by: SCALE DRAWN JOB. N0. 86.8 4 120" 86.4 120" Engineering Works HOOD SURVEY GROUP N.T.S. P.T.M. 257-06 t 12 West Crossfield Road P.O. Box 1724 DATE CHECKED SHEET NO. S.A.S. LAYOUT ; I' NO GROUNDWATER OBSERVED Forestdole, MA 02644 Mashpee, MA 02649 N.T.S. PERC RATE <2 MIN/IN. ("C" HORIZON — TP 1) 12 29 06 P.T.M. 2 Of 2 { (508) 477-5313 (508) 539-7799