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Home My WebLink About0047 SHOREY ROAD - Health 47_SHOREY RD, HYANNIS A = o Feb; 16 12017 00:04 Jim The Inspector Man 5085349919 page 1 t Fi.i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments 47 Shorey Road r\3 Property Address Brendan & Katie Butler Owner Owner's Name t�s information is required for every —.Hyannisport MA 02647 2-10-17 �t page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when A. General Information �7 filling out farms S�� a��t3-- \l\lllllftl11111!//// on the computer, `\gyp XtH OF1NgSs9�•� use onlythe tab ��` P 1. Inspector: c key to move your :' y cursor-do not James D.SearS JA M ES use the return _ ; key. Name of Inspector Capewide Enterprises =* ' • � c+ o � : Company Name 153 Commercial Street IN SP`EG\0' Company Address ' Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 2-13-17 jk%pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 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 how the system will perform In the future under the same or different conditions of use. t5ins.dac•rev.6116 - Title 5 official Inspection Form:Subsurface Sewage Disposal System-Pegs 1 of 17 Feb 16 2017 00:04 Jim The Inspector Man 5085349919 page 2 r , Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Shorey Road Property Address Brendan & Katie Butler Owner Owners Name information required for every Hyannisport MA 02647 2-10-17 page. Cityfrown State Zip Code" Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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 system is a 1000 Gal. Tank D Box and eiohteen chambers 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or 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.doc•rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Feb 16 2017 00:04 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Shorey Road Property Address Brendan & Katie Butler Owner Owner's Name information is required for every _ Hyannisport MA 02647 2-10-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. B) System Conditionally Passes(cont.;): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N - ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system Is notfunctioning 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 151ns.00c•rev.6115 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 3 or 17 Feb 16 2017 00:04 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title, 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y< 47 Shorey Road Property Address Brendan&Katie Butler Owner Owner's Name information is required for every Hyannisport MA D2647 2-10-17 page. City/7own 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 wafers 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 is less than 6"below invert or available volume is less than Y2 day flow 4£AClll vC 151ns.doc-rev.6116 Tille 5 Official InsFedion Form:Subsurface Sewage Disposal System•Page 4 of 17 Feb 16 2017 00:04 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments F 47 Shorey Road Property Address Brendan & Katie Butler Owner Owner's Name information is H annis ort required for every — Y p MA 02647 2-10-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of.a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form,] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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.doc-rev.Gil Tide 5 official Irspecdan Form:Subsurfeoe Sewage Disposal System•Page 5 of 17 Feb 16 2017 00:05 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form 1111�wotj Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Shorey Road Property Address Brendan & Katie Butler Owner Owner's Name information is HyannlSport required for every MA 02647 2-10-17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information,was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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 Sol] Absorption System(SAS)an 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.doc-rev.6116 TWO 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 6 of 17 Feb 16 2017 00:05 Jim The Inspector Man 5085349919 page 7 44 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Shorey Road Property Address Brendan & Katie Butler Owner Owner's Name information Is required for every Hyannisport MA 02647 2-10-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and eighteen chambers. Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available y 9 (gP ))�( usage ears 2 last d NA . Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date CommerciaYindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(9Pd) Basis of design flow(seatstpersonslsq.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: 15ins.doc•rev.6116 Title 5 Official Inspection Form Subuesoa Sewage Disposal System-Page 7 or 17 Feb 16 2017 00:06 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Shorey Road Property Address Brendan b Katie Butler Owner Owner's Name information is Hyannis port required for every p MA 02647 2-10-17 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping. 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): 15ms.doc•rev.5116 Title 5 Off cial Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 Feb 16 2017 00:06 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5. Officiai Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Shorey Road Property Address Brendan & Katie Butler Owner Owner's Name requirelifo is Hyannisport MA 02647 2-10-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cons.) Approximate age of all components, date installed (if known)and source of information: Tank na / Box and leaching 2012-Permit#2012-73. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): 40" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ;❑ other(explain): Distance from private water supply well onsuction fine: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40 Septic Tank(locate on site plan): Depth below grade: 301, feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: Z" t5ins.doc•rev.6116 Title 5 official Irspection Forn:Subsurface Sewage Disposal System-Page 9 of 17 Feb 16 2017 00:06 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts v Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Shorey Road Property Address Brendan & Katie Butler Owner Owner's Name information e required for every —Hyann,isport MA 02647 2-10-17 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont,) Distance from top of sludge to bottom of outlet tee or baffle 28'1 Scum thickness 1�� 8 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Plan -Tape 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.): Tank at working level. Tank at 30" below grade w/center cover at 1'. Outlet tee . No sign of leakage or over loading, 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.doc•rev.6116 Title 5 Official Inspection Form:Svbawfeoe Sewage Mapoaal Syalem•Pape/0 of 17 Feb 16 2017 00:07 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Shorey Road Property Address Brendan & Katie Butler Owner Owner's Name information is Hyannisport MA 02647 2-10-17 required for every page. CkyfTown 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 j❑ 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.); i Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ina.doc-rev.6116 Title 5 Offidal Inoeceon Form:sutsurface Sewage Disposal system-Page 11 of 17 Feb 16 2017 00:07 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Shorey Road Property Address Brendan & Katie Butler Owner Owner's Name information is required for every Hyannisport MA 02547 2-10-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-41" below grade wlcover at 18" . Box is clean and solid wlthree line's out. No sign of over loading or solid carry over. 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: 150e.cloc-rev.6/16 Title 5 Official Inspection Form:Subsurlace Sewage Disposal Syslem•pskge 12 of 17 Feb 16 2017 00:07 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments z 47 Shorey Road Property Address Brendan & Katie Butler Owner Owner's.Name information is required for every Hy annisport MA 02647 2-10-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: z leaching chambers number: 1 18- ❑ 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.): Leaching is 18 Biodiffler's three rows of six per row. Ck D Box and camera out lines to chambers. Clean and wet bottom No sign of overloading solid carry over or holding water, 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 z Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ns.doc•rev,6116 Title 5 offdai inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Feb 16 2017 00:07 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Shorey Road Property Address Brendan & Katie Butler Owner Owner's Name information is required for every Hyannisport MA 02647 2-10-17 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.): 15ins.doc-rev.6116 Title 6 Official Inssection Form:Subsurface Sewage Disposal System-Page 14 of 17 Feb 16 2017 00:08 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Shorey Road _ Property Address Brendan & Katie Butler Owner Owner's Name information is Hyannis port for every ort MA 02647 2-10-17 P page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below El drawing attached separately A 1�F�aR Q 8-1 = 39 'ZECK -3- t 9 • f r,4 A/11-5 3 a 33 '~ 3- t5irs.doc•rev 61115 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Pape 15 of 17 Feb 16 2017 00:08 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Shorey Road Property Address Brendan & Katie Butler Owner Owners Name requiredfonformaUon Is Hyannisport MA 02647 2-10-17 required for every page. Cityrrown State Zip code Date of Inspection D. System Information (cont.) Site Exam. ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 0 N 1. Estimated depth to high ground water: 10.8 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: 3-22 -12 Date ❑ Observed site(abutting propertylobservation 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: T.H. on design plan 3-22-12 no G.W. at 10'-8". Bottom of chambers at 4'-6"below grade. Bottom of chambers at 6' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins doc-rev.5116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 d 17 Feb 16 2017 00:08 Jim 7be Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Shorey Road Property Address Brendan & Katie Butler Owner Owner's Name information is i required for every Hyannisport MA 02647 2-10-17 page. CitylTown State Zip Code Date of Inspedion 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 r 15ins.doc-rev.U16 Title 5 Official Inspection Form:Subsurface Sewage Dieposel System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION � � � SEWAGE VILLAGEy�,f5,4_,, ASSESSOR'S MAP&PARCEL ` INSTALLER'S NAME&PHONE NO. CYAO SEPTIC TANK CAPACITY LEACHING FACILITY:(type)�� p (size) NO.OF BEDROOMS OWNER PERMIT DATE: '3 — COMPLIANCE DATE: �— Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fac' 'ty f Feet FURNISHED BY J l-- © 005 A P( -3, 33- ��' 7-5 No. Fee v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes P ltlfftati0n for isp08aI psfrm Const ution Permit Application for a Permit to Construct( ) Repair( ) Upgrade(N Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. / �—'/N Owner's Name,Address,and Tel.No. Assessor's Map/Parce Installer's Name,A dress,and Tel.No. �� -Designer's Name,Addre� and Tel No,,e� Type of Building: 7 Dwelling No.of Bedrooms Lot Size le, sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) � gpd Design flow provided i gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S. . ®' Description of Soil Nature of Repairs or Alterations(Answer when applicable) Oct,- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. S, i Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued - _ 1w- . 5 �.�..._..y, , •— ,,.,,,.„ .s:'..::..x.�+:-...r....�,M.s...:.a:.e,.sr,ra,•».y.,..-,nd^+. r...+.......ew ,.r=...0.....-...^...-...-. .,.. _ .... 12 No. C)"`/ Fee C/v --- -' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppIication for Dispo `-poem Construction Permit a Application for a Permit to Construct( ) Repair( ) Upgrade(`' A Sidon( ) ❑Complete System ❑Individual Components Location Address or/Lot No. / S U '= Owner's Name,Address,and Tel.No.,GW Assessor'sMap/Par Installer's Name,A dress,and Tel.No. ff��/ Designer's Name,Address,and Tel.No-,, �//b /� c�1 -Type ol"Building 1 Dwelling No oBedfooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) � gpd Design flow provided ! i U gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank t Type11(of S. Description of Soil, Nature of Repairs or Alterations(Answer when applicable) �r�' J� ®� cl_ t Date lastainspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. S'gned� � � ��, Date e, Application Approved by Date Application Disapproved by Date for the following reasons Permit No. , -- Date Issued ,! THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-si`S age Di,�posaI system Constructed( ) Repaired(N Upgraded( ) Abandoned( )by at fa&Z 2n'Adted n accordance with the provisions of Title 5 and the for is osal System Construction Permit No.Q= 73ated 3/ 7 h A, Installer Designer #bedrooms "� Approved design flow d gpd The issuance of this permit sh Il n t be construed as a guarantee that the systerfi will func s sig ed. Date /_/��*�.. Inspect( --' No. �/ �`- 7� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Disposal 6ipstem Construction permit Permission is hereby granted to Construct( ) Repair( A-) IZI Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of thispermit. - -- / -- Dateroved by t _ Town of Barnstable pp1HE Qi+ Regulatory Services Thomas F 'Geiler,Director • miNsrABLB, HA �� Public Health Division Thomas McKean, Director 2.00 Main Street,Hyannis,MA 02601 Office: 508-362-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: �� Sewage Permit# — Assessor's Map\Parcel Designer: i 1 Installer: Address: 1c� Address: l On /7 was issued a permit to install a (date) (tnstal`er) '� septic system at �k-6 041413nu!'"based on,a design drawn by (address) dated 27611.111*1* (designer) - I certify.that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow, OF VIP- DA E M (I taller's Signature REGISiE�� .. QNITAR0\ (Designer's Signature) (Affix Designer's Stamp Here) - PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF: , COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form 3-267 4''doc I , r , fi j Town of Bahmstable. P#� 5 Department of Regulatory Services • I'ublieIealth Division Date ` �rrarsec$ ! , ¢ ems$ 200 Main Street,Hy#nnis MA 02601 3 ~lFD 6t►'t M Date Scheduled � Time Fee Pd. ,Foil Suitability'Assessmentfol Sewage Disposal Performed By: //`� )"`e�� Witnessed By: - S i LOCATION & GENERAL'INFORMATION Location Address . Owner's Name (i/� Tl/� 'L LI els •H�ktN vi-)'S VVA; I Address Assessor's Map/P4rcel: —(�7 /l I Engineer's Name _ i� NEW CONSi-RUtON REPAIR Telephone# 1 1 Land Use Slopes(%) v Surface Stones Alen,e Distances from: Open Water Body.> `'�7 ft Possible Wee Area-1 ZO—ft Drinking Water Well l o 40 ' / ft Other ft Drainage Way ft Property Line s SKETCH:($treet name, \' o£sz a 66'SL 11 ,o b tity to holes) N Obi ,y9'8 N u u _ 1) 0z 1 \\ �4 OR�O .-....,... _._, .. .,.� ..gym-�^.-..._.�,'�-�•^�,.ur«-�._,.._.,�.�......i'.-;_.....�i.-,.,�J�..�,:M t._' ,....--�.s - / X� of Q Fw � 1 /QJp • 1 xyM3nin0 a3r`va / a��17 - - � 1 \ 6 ---------- '6�2 AYM3AItl0 O00'S9 �- ' - - k. k• Parent material(geglogic) C�•-�� c �• ��-�7� � Depth to at.aroc � A Depth to Groundwater Standing Water in Hole:' A j Weeping from Pit Face _. .-` --�---- Estimated Seasonal high Groundwater ! _ DtTERMINATION FOR SEASONAL EaG H WATER TALE Method Used: I ]n. Depth Cibrserved standing in obs.hole: in. Depth td snll tttottles: it. Depth toiweeping from side of obs.hole: in. Oroundwnter Adjustment level Ad,factor.,.,.._.. Adj•fJraundwnterl evrzl,,e Index Well# — Reading Date: Index Well. v -- PERCOLATION TEST Date Observation ( t Time at 9" -.-=-----.. Hole# i t` �lt n Time at 6" Depth of Perc ( .• 11 Start Pre-soak Time.@ 10" Time 9„-6 ) End Pre-soak ! Rate MinJInch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original:.Public 1=e$ith Division Observation Hole Data To Be Completed on Back— ***If percola ibn testis to be conducted within 100' of wetland,you must first notify the Barnstable C6#servation DINision at least one (1)week prior to beginning. DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil.Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel inn 0 (0 A 67 DEEP OBSERVATION HOLE LOG Hole# V Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling' (Structure,Stones,Boulders. Consistent %Gravel) t DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders. Consistency. ra I .r Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No J Yes a- Within 100 year flood boundary No Yes i Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring perlious material? Certification I certify that on to Q� l (date)I have passed the soil evaluator examination approved by the Department of EnwroAmientalfPrptection and that the above,analysis was performed by me consistent with the re qu i e i g expertise n e ene ce described in 3.10 CUR 15.017. Signature Date 3 GAS Q:ISEPTIC\PERCFORM.DOC + UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box i Town of Barnstable Public Health Division 200 Main Street J. Hyannis; MA 02601 I I j ii 111 EE1111 tt{{ tt tt {{ if 1ii II I ��-rle�r�l�l��.!l.i�!{!SllI1�11liil!!!11lli.ttitl�l�_lt�ll:irliltl I' rf comPLETE THIS SECTION • • ON DELIVERY ■ Complete items 1,2,and 3.Also complete A ZU& item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse X dressee so that we can return the card to you. B. Received by(Printed Name) D e f elivery ■ Attach this card to the back of the mailpiece, or on thirfront if space permits. Lk D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No Ms Sheila Lune 47 Shorey Road Hyannis, MA 02601 3. Service Type ❑Certified Mail ®Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number i i f I 011 0 4 7(0 0 2�Q 1 4,45 2y5 5 2 5 9 *T (Transfer from smice fabeq PS Form 3811,February 2004 Domestic Return`Recglpt 2. 102595-02-M-1540 �J � •► d vz FS S �1�� A 1Tru Ln Li w �:find k'i Ln ru Ln Postage $ r-R Certified Fee ® Postmark O Retum Receipt Fee Here p (Endorsement Required) Restricted Delivery Fee (Endorsement Required) O Total Postage&Fees $ ra Ms Sheila Lune 47 Shorey Road i Hyannis, MA 02601 Certified Mail Provides: a A mailing receipt G A unique identifier for your m3ilpiece a A record of delivery k,.Ppt by the Postal Service for two years Important Reminders: m Certified Mail may ONLY be combined with First-Class Mails or Priority Mails. o Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. o For an additional fee, delivery,may be restricted to the addressee or, addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery': o If a postmark on the Certified Mail receipt is desired,please present the art-- cleat the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail.. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 Town of Barnstable Barifistable r. Regulatory Services Department AMmEflcaC j 0 D BARNS-TABLE, 639. Public Health Division O° �63q. �0 m Arf0 MAC p' 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7011 0470 0001 4525 5259 September 13, 2011 Ms Sheila Lune 47 Shorey Road Hyannis, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 47 Shorey Rd., Hyannis, MA was last inspected on 9/2/ 2011, by Shawn McElroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS. • Liquid depth in cesspool is less than 6" below invert or available volume is less than t/ day flow. You are ordered to repair or replace the septic system within six (6) months from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Documentl C� r�o �� ' I Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 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. A. General Information 1. Inspector: , Shawn Mcelroy Name of Inspector Upper Cape Septic Service Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 Cityrrown State Zip Code 1-508-495-0905 S 13971 Telephone Number License Number B. Certification r` I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection 65 was.p,rformed 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 .:z Title 5(310 CMR 15.000).The system: �� - 0.=Passes ❑ Conditionally Passes ® Fails 0")Needs Furth r Evaluation by the Local Approving Authority 9-2-11 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,:the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewag Disposal System-Page 1 iof 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 - page. CitylTown 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: 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): r t5ins-1111.0 Trde 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ;M 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 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 r . 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 ' 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 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Shorey Rd 7M - Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 page, Citylrown 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 failurecriteria 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- 1 0,000g pd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either`yes"or"no"to each of the following, in addition to the. questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 = W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 page. Cltyrrown 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. ® El Determined in the field (f 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments_ �M 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): . Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 9-2011 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 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): I General Information Pumping Records: Source of information: N/A 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 47 Shorey Rd Property Address Sheila Lurie - Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 1970's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30" 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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 24" feet Material of construction: ® concrete ❑ metal ❑ fiberglass El polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins•11/10 TRIe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "! 47 Shorey Rd �M Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 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 20 Scum thickness 3 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? Tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments °M 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 page. Cityfrown 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 El 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 page. Cityrrown 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 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.): 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-11/10 TRIe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): 6x6 block cesspool acting as leach pit in good condition with stain lines above inlet invert. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of.scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is H required for every annis MA 02601 9-2-11 y 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.): t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 17 I - Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form Not for Voluntary Assessments G'M 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 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 ❑ drawing attached separately A_ 3-3 A-0 - Yt ' -� 6-7 L 0 F- (95' t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 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: 12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: ® Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Trtle 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 47 Shorey Rd Property Address Sheila Lurie Owner Owner's Name information is required for every Hyannis MA 02601 9-2-11 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 m H .A. t5ins.11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ;71 =`= COMMO �NEALTH OF NLksSACHliSETTS .' EXECUTIVE OFFICE OF E1'VIRONb4E\TAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 01E R'I\TER STREET. BOSTOX MA 02106 (617) 292•5:3(Ill TRUDYCO\r Secre-ar, ARGEO PAUL CELLUCCI DA�'ID Cora STP. :HS 7tt1S5::.'.E Y Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 RV_ c��( PART A 1 CERTIFICATION Property Address: �1 �7RQ�,t.w ti Vr�"'SfW Name of Owner Address of Owner: Date of Inspection:. �' �,`� ` Name of Inspector:(Please Print G!r CC U 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5{310 CMR 15.000) Name: �-u I, Company At��. "�� c tn�L�a ....tom �19• oZti �f-y Marring Address:-'egr3 2.,1 _3 9L. • U r4 G Telephone Number: / Sow# /go- • �o CERTIFICATION STATEMENT certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: APasses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature Date: 3 . The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board.of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to ttre system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS �gT�v.r ��"a L-e.s tp.e.� vh\ S��'C-� C3.��12.J�, � �st�w� tnn yF-•1 J�� J r O f 1 • f �VE8 . �UA� 2 1999 DEPT revised 9/2/98 PY�clell, `o Pnmed on"It"Ied Paper A ' � 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 1 S�nov�� +roperty,Address: u 1 Jwner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CON DITIONALLY PASSES: , One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y. N, or ND). Describe basis of determination in all instances. If "not determined% explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of attached indicates that th e tank was installed within twenty (20)years prior to the date of the inspection: or Compliance( 1 9 the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. A _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9./2/98 rage.;� { - ir SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 31 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine wh will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or gged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface wa ers due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an o erloaded or clogged SAS or cesspool: _ Liquid depth in cesspool is less than 6" below invert or available vo me is less than 112 day flow. Required pumping more than 4 times in the last year NOT due t clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or priv is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I o 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 1 0 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well s been analyzed to be acceptable. attach copy of well water analysis for coliform bacteria, volatile organic compounds ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the toll ing: The following criteria apply to large systems in dition to the criteria above: The system serves a facility with a design flo of 10.000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment beca se one or more of the following conditions exist: Yes No the system is within 400 fe of a surface drinking water supply the system is within 200 eet of a tributary to a surface drinking water supply the system Is located i a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such sy em shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further i ormation. c revised 9/2/98 Pege4oru SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 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 t/eming to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 Cb)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AN/' nia WATER PP.LIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIH AND FETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption SAS) d the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has aseptic tank and soil absorption nd a SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption n he SAS is within 50 feet of a private water.supply well. The system has a septic tank and soil absorption the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water ana oliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and thnce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 �J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No . Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system has been receiving rwrmal flow *'C rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. )( _ The site was inspected for signs of breakout. *X _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)1 The facility owner(and occupants,if different from owner) were provided with information on the propermaintanan".of SubSurface Disposal Systems. l i revised 9/2/98 Page 5of11 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: �� t5h0 c. Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL:' Design flow: J3U g•p•d./bedroom. Number of bedrooms (design): Number of bedrooms (actual): Total DESIGN flow. 'VS0 Number of current residents: C> Garbage grinder(yes or no): i Laundry(separates ystemPes or no): V� ; If yes, separate inspection required Laundry system inspecter nol Seasonal use (yes or no): Water meter readings, if available (last two year's usage (gpd):N Sump Pump(yes or no): Last date of occupancy: v S COMMERCIALIINDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)— Non-sanitary waste discharged to the Title 5 system: (yes or no)_, Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE 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) UA Technology etc. Attach copy of up to date operation and-maintenance contract Tight Tank _Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: t 3�'�k 1� Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) +roperty Address: t-1,i Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site pl n) i Depth below grader Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: Aoi i k t tee or baffle: Distance from top of sludge to bottom of outle _ Scum thickness:_ H 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 dimensions were determined: 1. �r.0 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level relation to outlet invert, st ctural integrity, evidence of leakage,etc.) 1 GREASE TRAP; (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of1.1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Irnspecbon: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, insp/ction) (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal _Fiberglass_Polyethylene_ot r(explain) Dimensions: Capacity: gallons Design flow:: gallons/day Alarm present Alarm level: Alarm in working order: Yes_ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) � Depth of liquid level above outlet invert: Comments: _ (note if level and distribution is equal, evidence of solids ca ryover, 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 pump chamber,•condition of p mps and appurtenances,etc.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Lf 1 skq'kk Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS)-IAA (locate on site plan, if possible: exca tion not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:1_ Alternative system: Name of Technology: Comments: ( to condition of soil, signs of hydraulic failure, level of ponding, da soil, ondition of vegetation, et�.) St CESSPOOLS:WU (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction:.- Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) r revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Lo Stl"I' )wner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) LA L a I � Z 03 l c revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty Address: Owner: Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater____ USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cella-. Shallow wells , Estimated Depth to Groundwater 1 tSFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) i Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you eVtablisheddtnthe High Groundwater Elevation. (Must be completed) US•'Z--Q in\o revised 9/2/98 Page 11of11 TOWN OF ARNSTABLE LOCATION 7 ! SEWAGE # Vfi:LAiE - Gtti n S ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANKCAPACITY LEAC�MgG FACU IT Y: (type)�" (size) I— 16VI) G NO.OFBEDROOMS 3 bUELLIER OR OWNER F PERMITDATE: ��.°� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted,Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (df any wells exist on site or within 200 feet of leaching facility),. Feet Edge of Wetland and Leaching Facility(If any wetlands exist- within 300 feet gVeaching facility) �1 Beet Furnished by F M � � n c v � - ., �. 0 _ n �, � �� a ' �. U� .�, 10 � o .: L _ _ _ c TOWN OF BARNSTABLE LOCATION. %R&mSEWAGE # VILLAGE W, !�2l�tS QC11�� ASSESSOR'S MAP& LOT (v lAir INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY^ A bW wy l LEACHING FACU.ITY: (type) f umr-Inw C A: em s` (size) lC�t�Ci ct NO.OF BEDROOMS BUILDER OR OWNER V—SW\A'V,-3 fE DATE: COMPLIANCE DATE: Separation Distance Between the: 3. Maximum Adjusted Groundwater Table Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) u e Fee; Edge of Wetland and Leaching Facility(If any wetlands exist within 300 f.et of leaching facility) Feet Furnished by �� !, � � � v`� � w � - � g,� S, S � � � `_ 5 $ ' �� . �� ^ � � � d� N e r �I �� i ��'� �� 41 v..' .. �,� GENERAL NOTES. ` ;r LEGEND W. HYANNISPORT PROPOSED CONTOUR 1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL � ) 4 BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS PROPOSED SPOT GRADE OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE. \ / 1 LOCAL RULES AND REGULATIONS. O ——g$ —— EXISTING CONTOUR *^ o o D 0 s 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFlLL€D PRIOR:,_ + 96.52 EXISTING SPOT GWg v TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND TIE ► _ �► DESIGN ENGINEER. /-� / z O y4 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING \ i W— EXISTING WATER SERVICE FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN i ENGINEER BEFORE CONSTRUCTION CONTINUES. (G- TEST PIT p 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. \I y 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 0 �f d THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED a gEAC RD. • TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. p^/ CRAIG\M4 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY _ `\ \3 8g ft LOCUS THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 47 SHOREY RD. 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE V. / 3 38\ 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION X 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY �/ o LOCUS INFORMATION AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY TITLE REF: 12426/086 p ti \ 13. NO PRIVATE WELLS WITHIN 100 FT. OF PROPOSED LEACHING / / F o LOT PARCEL ID: MAP 267 PAR. 168 14. ALL PIPING TO BE 4 SCH 40 0 1/8"/FT (UNLESS SPEC. OTHERWISE) 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW / \\ AREA = 1 01 48 s f + FOR THE USE OF A GARBAGE GRINDER 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING ry SEPTIC SYSTEM DEXIS7-/N`G REPAIR PLAN W EL L�N� LOCATED AT: ' TOP- OF ND 47 SHOREY ROAD WATER LINE F '\ 39•70 N W. HYANNISPORT, MA 38 BENCHMARK PREPARED FOR TOP of CONS BOUND ELEVATION = 38.34 MARTIN SH EI LA 90 BARNSTABLE GIS DATUM LU R I E �� cqo �/ MARCH 25, 2012 f 33 TP-2 Of 5� EX15T. LEACH PIT _ ape o NOTE 1 O AR yGn msp ports �; ' M a o EX15T. 1 ,000G SEPTIC TANK 93. bci ° 1 VC PLAN m MEYER & SONS, INC. SCALE: 1 in = 20 ft a P.O. BOX 981 - 20 0 20 40 EAST SANDWICH, MA. 02537 I (508)362-2922 } SCALE: 1" = 20' SHEET 1 OF 2 J 1387 } NOTE: TO PREVENT BREAKOUT, THE PROPOSED ,r NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:34.66 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED SAS a T.O.F. EL.=39.10 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER 14' OUTLET AND SET TO 6" OF FINI&H GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) .AND SET TO 3" OF F.G. INLENO F.G. EL.=38.00t F.G. EL.=38.00t F.G. EL:37.9t F.G. EL: 37.65(MAX.) I ��' OF ass 1 9.45" DA E L = 10't 9" MIN COVER/ ± L = 15' L - 1O'(MAX INSTALL TWO INSPECTION PORTS (MIN.) \ 11 0 • S=.1% (MIN.) 36" MAX COVER 0 S-1% (MIN.) 0 S=1% (MIN.) 12.37" 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC 10" 14 8 10.38" TO NITAR�aa INV. 34.89 46"UOUID INVERT �INV.=34.64 INV.= 34.20 I. COUPLER DETAIL W GAS H 3 ROWS OF 6 UNITS ® 5'/UNIT + 1 COUPLERS 0 1.16'/UNIT = 31.16'/ROW 34.32 ovV.=34.49 SOIL ABSORPTION SYSTEM (PROFILE) EXISTING 1,000 GALLON SEPTIC TANK EXISTING OUTLET RESTORE VEGETATIVE COVER , BACKFILL WITH CLEAN PERC SAND TO TOP OF CHAMBERS 60' NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING F PIPE INVERTS PRIOR TO CONSTRUCTION 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT=TOP ELEV.=34.66 GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.= 34.20 `. INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 33.33 310 CMR 15.221(2) EXISTING SUITABLE 3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK 5' MIN. ABOVE BOTTOM 2.88' MATERIAL OF WITH 1500 GALLON SEPTIC TANK IF FAILED, T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH 3 x 2.88' = 8.64' DAMAGED, NOT H2O LOADING, OR UNDERSIZED. (6.40' PROVIDED) USE 3 ROWS OF 6-ADS ARC 36HC 4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL.=26.93 __ (H20) UNITS - NO STONE W/ 1 COUPLERS GAS ,BAFFLE AS REQUIRED IN EACH ROW SEPTIC SYSTEM PROFILE TYPICAL SECTION 16 N.T.S. HAS SOIL LOG P ' - 135�bS DESIGN CRITERIA DATE: MARCH 22, 2012 SECTION fa38 NUMBER OF BEDROOMS: 3 BEDROOM DESIGN SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE. #1614 INVERT SOIL TEXTURAL CLASS: CLASS I DESIGN PERCOLATION RATE: <2 MIN/IN WITNESS: DONALD DESMARAIS, BARNSTABLE BOH HEIGHT END CAP EloDAILY FLOW: 110 G.P.D/BR. DESIGN FLOW: 330 G.P.D. .70 TP- Depth 0" 37. TP-2 Depth 600" 37 ADS - ARC 36HC CHAMBER (H20 LOAD) A _ , GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) AND A LOAMY S3 2 LOAMY SAND MODEL ARC 36HC 10YR SEPTIC TANK: 330 gpd x 200% = 660 gpd USE EXIST. 1,000 GALLON SEPTIC TANK 37.20 B 6" 37 10 10YR 3 2 6" LENGTH 63" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT B EFFECTIVE LENGTH 60" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. LEACHING AREA REQUIRED: (330)/0.74 = 445.94 S.F. LOAMY 0YR 66//8D LOAMY SAND SIDE WALL HEIGHT 10.38" " 34.88 1oYR s/6 DISTRIBUTION BOX: 3 OUTLETS (MINIMUM) C 34 34.78 C 34" . OVERALL WIDTH OVERALL HEIGHT 16" 4640 TRUEMAN BLVD PRIMARY S.A.S. ' pert teat MEDIUM 10.7 CF E&TF)o HILLIARD, OH/0 43026 USE 3 ROWS OF 6 - ADS ARCHC 3616 H2O UNITS-NO STONE MEDIUM CAPACITY � • 33.28 SAND SAND (80.0-GAL) ADVANCEDDRNNAGE.SYSTEMS, INC.. AND EXTENDED 1.16 W/ COUPLER IN EACH ROW 2.5Y 6/4 2.5Y 8/4 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF/LF OF CHAMBER) VA VA PROPOSED SEPTIC SYSTEM SITE PLAN (CHAMBERS: 6/ROW)18 UNITS x 5.0 LF x 4.80 SF/LF = 432.00 SF 27.03 128" 26.93 128" (COUPLER: 1/ROW) . 3 UNITS x 1.1s LF x 4.so SF/LF = 16.70 SF 47 SHOREY ROAD, W. HYANNISPORT, MA __TOTAL AREA = 448.70 SF PERC RATE- <2 MIN/IN. ("C" HORIZON) Prepared for: Lurie DESIGN FLOW PROVIDED:. 0.74GPD/SF(448.70SF) = 332.03 GPD > 330 GPD req'd NO GROUNDWATER OBSERVED u, Engineering by: Surveying by: SCALE DRAWN 1 = MEYER&SONS,INC. Boo Tech Env. NTS D.M.M. 1, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP,pursuant to 310 CMR 15.017 pO BOX 981 -0894 to conduct Boil evaluations and that the above analysis has been performed by me consistent with the EAST SANDWICH,MA 02537 (508) 364 DATE: CHECKED SHEET NO. requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Evol. Exam in October, 1999. 508-362? 032512 922 / / D.M.M. 2 OF 2