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0014 SUMMER LANE - Health
1 1. ;y5411 I'N4_�7. 1�4:Summer Lane � F Hyannis-y d„(F � o a o l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name information is Hyannis Ma 02601 5/24/2021 nis required for every Hyan is State Zip Code Date of Inspection page. 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. Inspector Information t I* 19409 filling out forms on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane Company Address 02632 Centerville Ma State Zip Code Citylrown 774-248A850 smjonestitle5@gmail.com, SI4522 sean@sm"onestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/24/2021 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 has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Tdle s Ott dal Inspect on Form:Subsurface Sevrage GIs osa1 SYstem•Page 1 d 18 i t5ms�p.dbc•rev.7/?6f2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name , information' Hy Ma 02601 5/24/2021 required for Hyannis every State Zip Code Date of Inspection page. Citylrown C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: The property located at 14 Summer Lane Hyannis is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 5 Infiltrators.Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): r t5hsp.doc•rev.7/26=18 _ We 5 official tnspeaion Form:Subsurface Sewage Disposal System•Page 2 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name information is Hyannis Ma 02601 5/24/2021 required for every Citylrown State Zip Code Date of Inspection page. C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ ❑ N ❑ ND(Explain below): obstruction is removed ❑ Y ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR i 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: I nue s ofriew tnspection Fenn:Stbwftco Sewage Dlsposel System•Page 3 of 18 t5insp.doc•ray.7rffM18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name information is Hyannis Ma 02601 5/24/2021 required for every C ryRown _ State Zip Code Date of Inspection page. C. Inspection Summary {cont.) ❑ ' Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® 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 Titte s official inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 t5nsp.doc-rev.7/262018 ' 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owners Name information is Hyannis Ma 02601 5/24/2021 required for every Cityrrown State Zip Code Date of Inspection page. C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems:(cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below in or available volume is less than 1/2 day flow ® Required pumping more than 4 tim El in the last year NOT due to clogged or ' obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] El ® The system is a cesspool serving a facility with a design flow of 2000 gpd El gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. r"yes"or"no"to each of the following, in addition to the For large systems,you must indicate eithe questions in Section GA. Yes No p ❑ ❑ the system is within 400 feet of a surface drinking water supply I ❑ ❑ 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 i� Title 5 Official lnspaetion Foim:Subsurface Sewage Disposal system•Page 5 of 18 t tgaisp.doc•rev.M612018 i y t\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name information is Ma 02601 5/24/2021 required for every .Hyannis State Zip Code Date of Inspection page. City/Town C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must Indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® 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: ® ❑ 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)] rdte s ofttdat Inspection Form:subu dace sewage Disposal System-Page 6 of 18 61sp.doc•rev.7I2612018 I_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name informations Hyannis Ma 02601 5/24/2021 nis required for every Hyan is State Zip Code Date of Inspection page. D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual): 330 gpd DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? . I Water meter readings, if available(last 2 years usage(gpd)): I Detail: ❑ Yes ® No Sump pump? current Last date of occupancy: Date 1 I f rdle 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of IS t5insp.doc-rev.7/SM B Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name information is Hyannis Ma 02ate601 5/24/2021 required for every Cityf fo St Zip Code Date of Inspection page. D. System Information (cont.) 2. CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: I Last date of occupancy/use: Date Other(describe below): i 3. 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: Titto 5 omciai Inspection Forth:Subsurface Sewage Disposal System•Page a of 18 t5insp.doc•rev.72612018 t Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owners Name p2601 5/24/2021 information is Hyannis Ma required for every Ciyannis State Zip Code Date of Inspection page. D. System Information (cont.) 4. Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: system installed 2005 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1.5 Depth below grade: 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.): Joints in good condition, no leakage,vented through roof. r i Tdle 5 ofrxiet Inspection Forth:Subsurface Sewell°Disposal System•page 90118 l5'ersp.doc•rev.7/AMMI8 i I I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name information is Hyannis Ma 02601 5/24/2021 required for every y State Zip Code Date of Inspection page Cityrrown D. System Information (cont.) 6. Septic Tank(locate on site plan): 1 Depth below grade: feet I Material of construction: j ®concrete ❑ metal . ❑fiberglass ❑ polyethylene ❑other(explain) I I i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1500 gallons Dimensions: 5" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3' 21' Scum thickness 7„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 10" Opened covers and took How were dimensions determined? measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance.water level was even with outlet,tank was not leaking and was structurally sound. I t5insp.doc•rev.7I282018 Too 5 ofridal Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name information is H Ma 02601 5/24/2021 Hyannis required for every � State Zip Code Date of Inspection page cityrrown D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): i Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): S. 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 Tate s ofricial Inspection Form:Subsurtace Sewa96 Disposal System•Page 11 of 18 ' Wnsp.doc•rev.MGM`!8 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name information is Hyannis Ma 02601 5/24/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): i 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Oil 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.): Distribution box was found in good condition with no major rot.Water level was even with outlet invert. 15insp.doc•rev.7f26/2018. Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane — Property Address Robert&Suzanne Hallam Owner Owner's Name information is H Ma 02601 5/24/2021 Hyannis required for every y State Zip Code Date of Inspection page Cityfrown D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): •If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number. ® leaching chambers number: 5 Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: 15hW.doc•rev.7f MOI 8 Tine 5 Official hspection Forth:Subsuatace Sewage Disposal System-Page 13 of 18 I t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for-Voluntary Assessments d 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name 02601 5/24/2021 inforrnation is Hyannis Ma required for every City State Zip Code Date of Inspection page. D. System Information (cont.) 11. Soil Absorption System(SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): Leaching facility was video inspected and found with a few inches of standing water and no signs of past overloading. I 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer- Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r We 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of IS t5insp.doc•rev.MOWS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name information is Hy Ma 02601 5/24/2021 Hyannis required for every state Zip Code Date of Inspection Page Cityrrown D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t Idle 5 official inspection Form:Subuufaoe Sewage Disposal System•Page iS of 18 t5insp.doc•rev.72612018 f I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owners Name information is H Ma 02601 5/24/2021 required for every C �To annis is State Zip Code Date of Inspection page. wn D. System Information (cont.) 14. Sketch Of Sewage Disposal System: ' Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately v 3 � 3 � AZ C i . t5irtsp.doc•rev.7126/2018 Title 6 official Inspection Forth:Subsurface Sewage Disposal SYslem•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name information is Hyannis Ma 02601 5/24/2021 required for every gta� Zip Code Date of Inspection page. Citylrown D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 12'+ 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 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: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report,please see Report Completeness Checklist on next page. 1 t5irmp doc•rev.7126MI8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i r Commonwealth of Massachusetts Title 5 Offici'al Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Summer Lane Property Address Robert&Suzanne Hallam Owner Owner's Name information is Hyannis Ma 02601 required for every ` page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B_ Certification: Signed &Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included I • Winsp.doc•rev.7f2612018 Titles Official Inspection Forth:Subsurface Sewage Disposal System-Page 18 of 18 L e Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Summer Lane Property Address Hemr Owner's Name Hyannis 'MA 02601 2/19/14 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. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 Telephone 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 2/19/14 Inspector's ignatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. web.mail.comcast.net•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Summer Lane Property Address Hemr Owner's Name Hyannis MA 02601 2/19/14 i CityrTown 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: Pumping suggested every 3 yrs to prolong the life of the system a 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: 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 web.mail.00mcast.net-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Summer Lane Property Address Hemr Owner's Name Hyannis MA 02601 2/19/14 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: 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 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. web.mail.comcast.net•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts REM Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Summer Lane Property Address Hemr Owner's Name Hyannis MA 02601 2/19/14 City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a 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 El ® 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 '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. web.mail.comcast.net•.03I08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Summer Lane Property Address Hemr Owner's Name Hyannis MA 02601 2/19/14 Cityrrown State Zip Code Date of inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet j 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 i 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. web.mail.comcast.net-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts 4 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Summer Lane Property Address Hemr Owner's Name Hyannis MA 02601 2/19/14 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® 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)] web.mail.comcast.net•03/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Summer Lane Property Address Hemr Owner's Name Hyannis MA 02601 2/19/14 Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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 years usage(gpd)): Sump pump? ❑ Yes ❑ No Last date of occupancy: June 2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): n/a web.mail.comcast.net-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 14 Summer Lane Property Address Hemr Owner's Name Hyannis MA 02601 2/19/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Pumped 2yrs ago per owner. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2005 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No web.mail.comcast.net•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 14 Summer Lane Property Address Hemr Owner's Name Hyannis MA 02601 2/19/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): • 18„ Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): >10' 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: 12"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: 1500g Sludge depth: trace Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace >2" Distance from top of scum to top of outlet tee or baffle >2 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured web.mail.comcast.net•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Summer Lane Property Address Hemr Owner's Name Hyannis MA 02601 2/19/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee.or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a 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): n/a web.mail.comcast.net•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Summer Lane Property Address Hemr Owner's Name Hyannis MA 02601 2/19/14 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): n/a `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 01. 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 2'6" below grade, cover raised to 12"of grade, average condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No i web.mail.comcast.net•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Summer Lane Property Address Hemr Owner's Name Hyannis MA 02601 2/19/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5 infiltrators per plan ❑ 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.): Infiltrators were video inspected and were dry at the time of inspection, no indication of past backup web.mail.comcast.net•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Summer Lane Property Address Hemr Owner's Name Hyannis MA 02601 2/19/14 City(rown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool I Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a web.mail.comcast.net-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Assessing As-Built Cards Page 1 of 1 TOWN OF BARNSTABLE LOCATION `� 50/37'r Q LA✓i SEWAGE Qo 21 Y- VILLAGE ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. 4 z ti Q1N s r re)s r 7 3 G� SEPTIC TANK CAPACITY /S D o LEACHING FACII,TI'Y:(type) S!7 r R A r ort f (siu) NO.OF BEDROOMS_ BUILDER OR OWNER W /r rc f e� rAf3 S PERMTTDATE: /C/.a l AS COMPLIAI3CE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1 r i ^ ) P 32, -s- r 7,7 F • Q v )3o to No 7 70 :5 g�� http://www.town.bamstable.ma.us/assessing/ffMdisplay.asp?mappal=288113&seq=1 2/20/2014 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Summer Lane Property Address Hemr Owner's Name Hyannis MA 02601 2/19/14 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: per elevation of home i web.mail.comcast.net•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 TOWN OF BARNSTABLE LOCATION /4/ SEWAGE #aOo-S- VILLAGE ASSESSOR'S MAP & LOT W0 INSTALLER'S NAME&PHONE NO.P4 z H 6 sT rd SEPTIC TANK CAPACITY I G O A/, LEACHING FACILITY: (type) 5-1 ,✓r /72 A rant (size) X 3-3_�X /d% NO.OF BEDROOMS 3 BUILDER OR OWNER /r�f PERMTTDATE: ACIA E c::_� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ' Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ?s Pdl � 4 a ../ l Gl LY '� QD rs 4 � z V v V (Z �u Iu a No. Fee Yes THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Migpotaf 6pgtem-Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) O Complete System O Individual Components LpcAon Address or Lot No. Owner's Name,Addres and Tel.No. Ass ssor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. A/LG.s c3'Oi � 7s /36 s�o 77� ' � of7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 5 gallons per day. Calculated daily flow 3 Q gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 a e the ystem in operation until a Certifi- cate of Compliance has been ' e is Board of Health. Si Date Application Approv by Date Application Disapproved for the following real s i i I Permit No. Date Issued •..�a>w7a`2,�„ a;ru,_ �_ .� Y y. _f`_ �.. -,T, w•�;w- ..�: � ,.,-.:+ ... � ,....... „y�.;, _,. %''1 �.♦ 'K► I �Xssb�T`.•1 Fee No. � � �r,.�. THE COMMONWEALTH OF MASSACHUSETTS"' Entered in computer: Yes i PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Migpoaf *pMem Construction Permit Applicatt n for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) D Complete System 13 Individual Components Lo Address orL of No. // Owner's N e,Address d Tel. -11 Assessor's Map/Parcel . 1 a. Installer's Name*Address,and Tel.No. Designer's Name,Addreessq/�d Tel.No. S' Oi /36 S oe ; Type of Building: _ Dwelling No.of Bedrooms Lot Size sq. ft. I _`Garbage Grinder.( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow l gallons per day. Calculated daily flow 3 y gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. j J a, Description of Soil f •-p Nature of Repairs or Alterations(Answer when applicable) F ' 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.ystem in operation until a Certifi- cate of Compliance has been issudd his Board of Health. / -w- Signed� Date �.' Application Approved by 4 - Date Application Disapproved for the following reaso Permit No. C4tIvi — Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE; MASSACHUSETTS " Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired ( ) Upgraded Abandoned 9 12 e- /T at L;- 2 _ f as constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No ated Installer GZ e/7' Designer �a.✓ Gip . 49 c The issuance of this permit sha7 a construed as a guarantee that the ystem 1- e'on as designed. Date J aJ'ry7 Inspector_.1, �`"��-----��� Fee-- .-�-� THE COMMONWEALTH OF MASSACHUSETTS _ PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Miopogar *p2;tem'Con!5truction Permit Permission is hereby grant t I nstru t( )Repair( )Upgrade Abandon( ) System located at _ !/ c L_ g / F 4—, i9 S 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:Construe/ion mu t be completed within three years of the date of this e /0 7 /Dater Approved by ! t III Town of Barnstable Regulatory Services . Thomas F.Geiler,Director MAM Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office.: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form t Date: ZZq O Designer: I L Installer: n V_Ck CO Address: Address: Z3 bX 5 Y ph e✓,i/ r' On Jr- was issued a permit to install a (date) (installer) septic system at t y Svc, �—<1 .r/E based on a design drawn by (address) - . J • CAT> dated S 3 200 /' (designer) l�I%ertify 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. RONALD 9y� j o JAMES N CADILLAC er s Sign atur o #106 1 o � '9 /STEP sq�11 TAP\P (Designer's i afore} (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC 131AALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOT111 THIS FORM" AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE P LIC HEALTH DIVISION, THANK YOU. Q:Health/SepticMesigner Certification Form - TOWN OF BARNSTABLE LaATION a SEWAGE # YI LAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY FAILED rt r_n IN8P,E- ►°T1,OwI 1 t LEACHING FACII.TTY: (type) C—S s,,ems '1 (size) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by—il Ili 11 /d j 70 / TOWN OF BARNSTABLE L(,('ATION M SU ►w in a ►.. J.Ct n -p— SEWAGE # VILLAGE ASSESSOR'S MAP & LOTaK 113 iNSr' T 72'ov 61 "4 L V o 1 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) M (size) NO.OF BEDROOMS a M DER OROWNER ,Z[ PERMITDATE: ' COMPLIANCE DATE: Separation Distance Between the: - Maximum Adjusted Groundwater Table to-the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching'-facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ALWAYS DIG SAFE PRIOR TO CONSTRUCTION--UTILITY LOCATIONS SHOWN INCOMPLETE. JOB NO. B05-04 NOTES Calmus2.dwg N MAXIMUM FEASIBLE COMPLIANCE APPROVALS REQUESTED: 1. LOCUS IS A.M. 288, PARCEL 113. 2. ELEVATIONS SHOWN ARE ASSIGNED. 6 1. NO RESERVE AREA IS PROVIDED. 310 CMR 15.248. 3. LOCUS IS IN FLOOD ZONE B ON FIRM DATED JULY 2, 1992. w REDWOOD LANE 4. ALL PIPES TO BE 4" SCH 40, AND PITCHED AT 1/4" PER FOOT. (UNLESS NOTED) Q 0 5. MUNICIPAL WATER IS AVAILABLE. LOTS WITHIN 100' ARE ON TOWN WATER. 2E 6. COMPONENTS TO BE AASHTO H-10, UNLESS NOTED. w m 7. INLET TEE TO PROJECT DOWN 13", OUTLET TEE DOWN 14". 0 8. IF TWO OR MORE LINES, WATER TEST D-BOX FOR EQUAL FLOW :3 � SCOALEO o_ N/F D-BOX EXIT PIPES TO BE LEVEL FOR FIRST TWO FEET. cn N SULLIVAN 9. DEPTH OF COMPONENTS NOT TO EXCEED 3', OR VENTING MUST BE PROVIDED. 10. STONE TO BE DOUBLE WASHED 3/4 TO 1 1/2" WITH 2" MIN. 1/8 TO 1/2" PEA STONE ON TOP. 11. IF UNSUITABLE SOILS, OR SOILS DIFFERING FROM THE SOIL LOG ARE FOUND, LOCATION MAP / CONTACT THE BOARD OF HEALTH, OR R.J. CADILLAC. 12. IF AN OVERDIG IS CALLED FOR BELOW, FILL MATERIAL FOR 5' AROUND AND UNDER LEACHING IS TO BE CLEAN GRANULAR SAND MEETING SPECIFICATIONS OF 310 CMR 15.255(3). 13. PUMP AND FILL ANY EXISTING CESSPOOLS. REMOVE ANY CLOGGED SOIL, BLOCK, AND STONE IN TEST HOLE 1 LEACH AREA, AND DISPOSE OF AS DIRECTED BY HEALTH AGENT. 14.5 14. ALL CONSTRUCTION TO MEET TITLE 5 AND LOCAL REGULATIONS. qqO DEPTH (inches) ELEV.(feet) ® 14 37 P / 0 A layer 10yr 3/3 20.1 f �14.9 REPLUMB SEWER PIPES TO EXIT, AS SHOWN, TEST HOLE DATE: April 19, 2005 14" sandy loam USE H-20 LEACHING f WITH THE CENTER OF THE PIPE 2'-4" BELOW PERFORMED BY: Ron Cadillac, Soil Evaluator CARS PARKED OVER WITNESSED BY: Donald R. Desmarais, �' 14,86 � 15,2 �.`O 6, TOP OF BLOCK FOUNDATION. � " RS B layer 10yr 5/8 LAWN IN THIS AREA. <" k PERC RATE: <2 -00 /inch (C layer) loamy sand H N/F 20.96t SOIL SURVEY(1993): Carver coarse sand /�� 67 > �`30' j SOX HALLIDAY Top Exist. Foundation GEOLOGIC MAP(1986): Barnstable plain deposits 32" 17.4 / 15.3 � S,O"' \\X Invert 18.45 5 HI CAP H 20 �m C layer 2.5y 6/4 �� ., ' ) Invert 17.95 INFILTRATORS 46' a '� PROPOSED--REPLUMB " med. coarse sand 1 16.0 '� Proposed Invert 17.58 Provide 18 cover i \ 1. Use Gas Baffle 1 1 `; 16 8 9" min. cover Proposed 18 0 / 2 S=1/4"�ft " Top Peastone N/F / " .Ib `� 0 6 Monol the S=1 8 ft rI p " observed water / \ 1 -" .:. 21 c ns ection Port o Nc� J a.9 1500 Gal. 118 -------- 10.3 X Invert 18.20 CALMAS �14 O N 228 � C) } 2L I Proposed Septic Tank ------� no water od; (�T\ L 0 T 8 /� 10 1�4' 130" 9.3 y ,`==O ¢� 7530±S.F 1 - " Invert 17.75 Invert 17.5516.7 0 9,3 C� o BENCH MARK- N.E. CORN. OF I 6 Stone or compact Proposed Proposed I 5' Bottom CONC. STOOP= 21.17 ASSIGNED x 19.0 I I IN 7 �C/ R PLUMB 2Q, �Q4 I 12 -� j--18 -� I _r- 1 EI.=11.7 �15.01 / 98�\ l� r�``:.; m 1.4' USGS Adjustment 5 . / < \ �15, �, �q \ " _ �1 �21.5 DESIGN DATA Using MASH29-May 98 ti CFO - Zone B s9y2. - ryo O % Observed Water=10.3 40410 17,3 \ R/�F �• BEDROOMS: 3 ? ` ' N b o Q GARBAGE GRINDER: No 8.6 ..: :::: ::::::: :..�^ �p N N/F REQUIRED CAPACITY: 330 GPD LEACH AREA N/F �O' A USE 5 HIGH CAPACITY INFILTRATORS WITH / {• p cy DAVIS SEPTIC TANK: 1500 GAL. 17.0 ::::::� �� ::::::: nr COSTIN & TWOMEY �...... 2 BOTTOM LEACHING AREA: 396 SF APPROXIMATELY 2 OF STONE ON ENDS AND [(36' X 11')] 4 ON SIDES TO MAKE AN 11 X 35 X 10 1/4 o x �. .:. .:::. o ... .. ::::. �l LEACH AREA. ^ :?�,, 01 01 - SIDE LEACHING AREA: 79.9 SF 182 _"""' i'•::•:: [2(11 + 36 ) x 0.85' DEEP)] 5 REMOVAL W/ PARTIAL BARRIER .. .•. ` DESIGN CAPACITY. 352 GPD DO 5' ALL AROUND REMOVAL DOWN 32"f TO 3' DEEP IMPERVIOUS S y2�p : : 1 BDRM BDRM [(396 SF + 79.9 SF) X .74 GPD/SF] MEDIUM COARSE SAND. PROVIDE IMPERVIOUS BARRIER--63 L.F. OF Fryo ,� KITCHEN - BARRIER ON WEST AND SOUTH SIDES OF RE- 40 MIL POLYETHYLENE ,c MOVAL, AS SHOWN. (MILLER' BREAKOUT**) N/F TOP BARRIER=TOP PEA STONE=18.7 MIN. AYL 3 w 2 � BDRM BATH ROOM PROVIDE **MILLER ENVIRONMENTAL NCH MARK--TOP OF WE). STAKE TIE BARRICADE, 508-697-3710. SET FLUSH=20.36 ASSIGNED OR USE H-20 FLOOR PLAN BE NOT TO SCALE SEPTIC TANK INSPECTION SCHEDULE CALL R.J. CADILLAC TO INSPECT PRIOR TO BACKFILL. SITE PLAN FOR THIS PLAN IS A VALID COPY ONLY IF IT BEARS WILFRED E. CALMAS AN ORIGINAL RED STAMP AND SIGNATURE. LEGS LOT 8, 14(8) SUMMER LANE, HYANNISPORT, MA •J� TH 1 TEST HOLE LOCATION, NUMBER �L/(/ , MAY 39 2005 SCALE: 1 "=20' W- WATER LINE MARKINGS > ,` F OVERHEAD ELECTRIC WIRES (IF SHOWN) y 9.5 g,j EXISTING & PROPOSED ELEVATIONS ('X' MARKS POINT) cis,. ,.�gti�Es s\°o- � SA, r, SURJE �6--- EXISTING CONTOUR RONALD J. CADILLAC, PLS, RS, PC 8- PROPOSED CONTOUR f�j J��'. PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN 2n UTILITY POLE (IF SHOWN) P.O. BOX 258 ® EXISTING DRAINAGE CATCH BASIN WEST YARMOUTH, MA 02673 FENCE (IF SHOWN, NOT ALL SHOWN) (JOB) 775-9700 TREE (IF SHOWN, NOT ALL SHOWN) HEALTH AGENT APPROVAL DATE ©2005 BY R.J. CADILLAC PAGE 1 OF 1 Rcdwood tM .' "I"s aga / Iqq TOWN OF BARNSTABLE CATION L-qk SEWAGE # '�B7F'' _�' AGEE��w w\,s P� ASSESSOR'S MAP LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY C-eSSp CV L US Y,)O LEACHING FACILITY:(type) 01-e -14Sq—/T T (size) Ll tcto t J NO. OF BEDROOMS .3 PRIVATE WELL O AT I� BUILDER OR OWNER Q-<Z- DATE PERMIT ISSUED: �— DATE .COMPLIANCE ISSUED: . . VARIANCE GRANTED: Yes No ✓ �O7 `V � ASSESSOR'S MAP NO. PARCEL F S' I Sg Y L0";CA:T ION SEWAGE PERMIT kQ I TA LLER'S NAME ADDRESS I UIL0E R OR OWN ER DAj E, P. ERMIT I S S U CD OAT E C 0 M P L I A N C E ISSUED L y Fins THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. ...................0 F'...... ... ......................................... AV111tratinn� for Rsonsal Works Tonstrnrttnn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( fin Individual Sewage Disposal System.at: .......f 's .o k......... .�: 5..... ......................... ----------- - - ... ... ..._..............:. Location-Address or Lot N o. .5..---•........................ .........�14�` ......................................................... Owner Address a .� .K.. � u = = ..:. a .0 ....Y ........................................ } . Installer - Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms---.3.....................................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building............................. No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ......................•------ ----......... �. ..................:........................................................... WW Design Flow.....-C ...:..............:......gallons per person per day. Total daily flow........... .................:.gallons. WSeptic Tank—Liquid capacity......_.....gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width..................... Total Length........:.::........ Total leaching area....................sq. ft. 3 Seepage Pit No-------/........... Diameter...12�..._._ Depth below inlet*._....�(......_... Total leaching area..................sq. ft. Z Other Distribution-box ( ) Dosing tank ( ) -Percolation' Test Results Performed'by------------------------•----------.....•-----•---.............-------_-- Date------................................. a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.................... (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a+ •---•........... ..................................... ................................................................................................... 0 Description of Soil.............................................................................................--------••---•.........-------------•------.............................. W UNature of Repairs or Alterations—Answer when applicable..._...._ 'Y ...._.LFf~ .__.�{ o_._tl '.r I.-....:..__. ..--••-•-•-------------------------------------------------••-•-----•--•-•------•--------••-----••----....._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the lth. Signed...:....... ....------ --------- ----------= . •---•--•--•- ....Z .. Date Application Approved By............... -------• a `cs J Date Application Disapproved for the following reasons:...-............................................................................................................. ..................... .. ...............................---....•----------••-••-----.........--•---....._...................•............._------------.............. . ••........... Date Permit No..........5-87"_...1 1-��-------------------- Issued....................................................... Date v. 7. / THE COMMONWEALTH OF MASSACHUSETTS e " r +• •" 4• • 1 rti 4 BOARD OF HEALTH cz--_- ..._ ...� '. . -...,..OF.......� ..r..�:........C.... ...................................... A 'pliration fear Vispnsttl Works (> ons rurtiun'-prrutijt tr � Application is hereby made for a Permit to Construct (, ) or Repair ( —)-an Individual Sewage Disposal System at: f :.--•----�'- -_'� ,„F; •v;;a ..�-.' . ................................. - - v `D 4.crZ...... -- -...-•------- Location,- ....._............... . �—- Address s t __.. --•or Lot No. to�-..= ..................k!„.... .......-----------_.......................... ... Owner Address .........................�s. � .t- -------------------------------- -------------�_c� b �- �c ..12D........---------------................ Installer Address q� Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms...3.....................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) POther fixtures .._......--••---•--------------...............---...--.-----•-••-••--...--•-----•------• ............................................................. WW Design Flow...... ..........................gallons per person per day. Total daily flow....._._...7�.'..3 ...................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth........... x Disposal Trench—No:.................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit 0....... Diameter.._/.� _..... Depth below inlet..... .......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -----------------------•--••......-•....... .••••---•..............•-----•--------------------------•---------------•--•--------------•------•-•...... 0 Description of Soil...............................•...................---•-----......------••-----------------------------•----.........-------•----------------------.....--••-........... M V .-..--•--•------•---------- •-••-------------------------------- --------------- ------------------------ -------------------- •-•-••-•----------------- --------------------------- •....... .......... W U Nature of Repairs or Alterations—Answer when applicable_____-_f9- ....__nu- ..___ x ._.e1 .. I�� ................ r� 'c'' z C�.,S.<_•�d:o 1.--:....................•-•---••-------••--------........-•----•-•------•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance been issued by the board-of-health. Signed-,,---.-`,• � � �- a � Date Application Approved By................ . ........ ........................ ......... Date g& Application Disapproved for the following reasons:-----•--------------•-------------------------------•-------....------.....•.....----------•----..............- ....................•-••---•-•---•-•..._.............-••-•---............-••--•--------•-•....•••••••-•--.......-----•---------------•-•------•----•---••-----•--•••--••-----•--... •--...---•--. Date Permit No........... _..�s��.�................... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..,.......OF.,.,....9��.€�...✓..v�Sc_. .. ............................... (9rrtif iratr of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( `)� by------------------- L �-� 1 / Installer at.................(�— ....9:e SLL crrr� L-C.. .....................<.,w+- s c'J?2x` has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........ ...I I'3--... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................Ll .... Inspector =------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......OF........ r. No..- ...... FEE........................ Disposal Works Tunotrnrttivit rrntit Permission is hereby granted........ ..... to Construct ( ) or Repair (c_)-an Individual Sewage Disposal System at No.: ( ...._..r., �a. , __ ��.... ... r ,s '. 200:i-- .---- _... ---------------- ------... ...-•-.............-•-------•••-•-•--...........---•...... Street as shown on the application for Disposal Works Construction Permit No......gg:......�� .K Dated_......................................... Board of Health DATE --------••---.._......................................................