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0037 SUNNY-WOOD DRIVE - Health
37 SUNIVYWOnD DRIVE, HYANNIS -A= 273 234 - - - --- �I i � o a4-3_ a.a� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Na information is H annis V Ma 02601 3/11/2021 required for every y page. Cityrrown 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. Inspector Information 6-1:W 1 .6aLt3 filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Company A Lane Co � Company Address Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonestitle5.com License Number B. Certification I certify that: 1 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 Ap73/11/2021 thority 4. ❑ Fails 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. t5insp.doc•rev.7/26/2018 7Ale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 37 Sunny Wood Dr Hyannis is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit. 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form U1 . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is Hyannis Ma 02601 3/11/2021 required for every y page. Cityrrown State Zip Code Date of Inspection 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): ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 page. CityrFown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] i i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M (� 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 page. Citylrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No ` Last date of occupancy: un known Da t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantityy pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: original system installed 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 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. 1 I t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): •Depth below grade: 1feet 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 gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' I Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 , c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is H annis Ma 02601 3/11/2021 required for every y page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ Nci* 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: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ Leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is Hyannis Ma 02601 3/11/2021 required for every y i page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was located and excavated, pot was found with 1' standing water and a stain line 3' higher. 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.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 15 of 18 Commonwealth of Massachusetts � Title 5 Official Inspection Form V.'� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 pale. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately EE � 1 L A-( 3 t 31 4� y� Iq3 ;S b �3 2,0 �3 3 L/ 15insp.doc•rev.7262018 Intle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form uq,- � Q Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. 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: Groundwater was established by accessing town of Barnstable groundwater contour maps. - 1 A Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7262018 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e 37 Sunny Wood Drive Property Address Beatrice Puchol Owner Owner's Name information is required for every Hyannis Ma 02601 3/11/2021 page. Cityrrown 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 t5insp.doc•rev.7/26/2018 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 16 A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION roRH Address of property Owner's name Ste '^ y wv o ✓, c�4 S A4 K Date of Inspection ( ( 95 PART A CHECKLIST iCheck if the following have been done: V Pumping information was requested of the owner, occupant, and Board d of ✓ None of the system components have been pumped for a two and the system has been receiving normal flow rates during tthat weeks period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sew _g age back-up. The site was inspected for signs of breakout. A1'1 system components, excluding the SAS, have been located site. on the ✓ The septic tank manholes were uncovered, opened,P , 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 SAS on the site has b een on existing information or approximated by non-intrusive methods. r The facility owner (.and occupants, if different from owner) were provided with information on the proper maintenance of' SSDS. 10 1b N e0 ; i SUBSURFACE SEWAGE DISPOSAL SYSTEM 'INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential _? number of bedrooms �2_ number of current residents &/o garbage grinder, yes or no' E 5 laundry connected to system, yes or no _ Flo seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: �1�// �S 66/a/� �4 //o'1s 6� Last date of occupancy GENERAL INFORMATION Pumping records and source of information: '� ++ L+o System pumped as part of inspection, yes or no if yes, volume pumped 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) Other (explain) Approximate age of all components. Date installed, if known. S.ource of information: G 42 /�y Sewage odors detected when arriving at 'the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEX INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade:- material of construction: ,concrete metal FRP other(explain) dimensions:_ .S / L I � X A6 f � b c>0 sludge depth distance from top of sludge to bottom of outlet tee or baffle scum thickness " ,,scum thickness from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle 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 leak ge, recommendations for repairs, etc. ) "�d( - W o v v��. L✓ v m +^ �. e- U ✓ r O i .G c A @� t!J CJ ✓H !> : 4 4' t q A -fCi� "� �'t o v✓ . DISTRIBUTION BOX: (locate /on ..site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage i to or out 9 of box, recommendation for repairs, etc.) 36'r �/ 4-1 &4 ! e CJ— � CA lit PUMP CHAMBER (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possib e; excavation not re approximated by non-intrusive methods) required, but may be If not determined to be present, explain: Type. leaching pits and number ' leaching chambers and number (Oct L �' X 6 leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, conditin of vegetation, recommendations for maintenance or repairs,etc. ) Suh C� � L� CESSPOOLS (locate on site plan) : NI/9 number a:nd'- donfiguration depth-top . of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ) • 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE E:SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' 1 55�(,'' -D y3� . jy6 �� 1 V T 61XC L 1 DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: yf ✓ l: BQBSORFACE SEWAGE DISPOSAL SYSTEK INSPECTION FORK PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? �A Liquid depth in cesspool <6" below .invert or available volume< 1/2 dad flow? � 7 Required pumping 4 times or more in the last year? number of times pumped AL Septic tank is metal? cracked? structurally-unsound? infiltration? substantial exfiltration? tank failure imminent? al Is any portion of the SAS, cesspool or privy below.. the high groundwater elevation? -.1 within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? _ I within a Zone I of a public we l? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well .water ana1K. . for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 ' SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPECTION FORH PART D CERTIFICATION Name of Inspector ro �— Company Name Company Address Z/v S s Ol j . Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Chec one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have- determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature Date original to system owner Copies to: Buyer ( if applicable) Approving authority V.✓o u C/-. r; • �w1e Fl� �4 3a� L.O..CAT10N Hooze-?v-•37 SEWAGE PERMjT: :.NQ. i� V.ILLACE I:.NSTA LLERIS NAME ADDRESS 77. s:..0 I L D E R OR OWNER � . X. DkTE PERMIT ISSUED DATE COMPLIANCE ISSUED � Z i i TOWN OF BARNSTABLE YS LOCATION- ? .5�,,,�,,, w�o� 2�,- SEWAGE # VILLAGE ASSESSOR'S MAP & LOT o'�73 INSTALLER'S NAME & PHONE NO. c k-ex SEPTIC TANK CAPACITY 10 o D LEACHING FACILITY:(type) �X� f t (size) NO. OF BEDROOMS oC PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Fey. c, o DATE PERMIT ISSUED: It DATE COMPLIANCE ISSUED: $�S VARIANCE GRAN' D: Yes No 1 vi w p eC —f- � y W \ 1 1\ I / -L�("t-A T 10N t4ouz)e-9,f- 37 S E W A G E PERMIT NO. 10 Gov" LIB -Ib �G �j VILLAGE I N S T A LLER'S NAME A ADDRESS _ R U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED - `' .a l� Lj `e 7 4 ...........................No..... .. THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH ..............T.OWN.................OF........PARNSTABLE ........... ...................:........................................................... Appliration for Uispwial Marks Tonstrurtion ramit Application is hereby made for a Permit to Construct ( X) or Repair an Individual Sewage Disposal System at: Lot #45 ................................................................................................ .................T................................................................................ Capricorn Re&!Eaey-tttjsSt Sunny Wood L0&jf&No. ..............M .................................................................................................. (4 ��.er Hyannis Address .............. ..... . ........ .................................... .................................................................................................. .......... Installer Address Type of Building Size Lot.._._., .....Sq. feet Dwelling—No. of Bedrooms....................3......................Expansion Attic Garbage Grinder (nd) Other—Type of Building .............................No. of persons..............;............. Showers Cafeteria P4 Other fixtures ............................................................................................ **_*...*--------------------------------------------- Design Flow.......................5.5................gallons per person per day. Total daily flow................U.Q...................gallons. Septic Tank—Liquid-capacity...!Q.Q.Jallons Length1.!.-.6.!!. Width..4-10.. . Diameter................ Depth.... x Disposal Trench—No..................... Width..............._.... Total Length......................Total leaching area....................sq. f t. Seepage Pit No........_._1....... Diameter........U....... Depth below inlet....5..6:Z..... Total leaching area....25�_.....sq. f t. Z Other Distribution box ( X) Dosing tank ( ) Percolation Test Results Performed by......Eldre .......... Date.....I Z-Q7 18/8 Test Pit No. 1.....?.........minutes per inch Depth of Test Pit.....1?......... Depth to ground water fr4 Test Pit No. 2................minutes per inch Depth of Test Pit..__._.............. Depth to ground a . ........... ----------------------------------*....................**..................................................................... STEPHEA.... 0 Description of Soil 0-241.......jp!p�M.and__. . ..sub.s.o.i.1......2A1'_-_7.2.7._..meA1'.UM................. ......ALLYN...... sand and-rocks: 72"-144" medium sand . ....................... La WILSON U ..............................................I......................................17.................................... . ......... ........*-- --- ----- W .................................................................................. .............................................................K................ U Nature of Repairs or Alterations—Answer when applicable.................................................................. .. . ....... . ........................................................................................................................................................................... Co Agreement:` The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I TL 1E 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 rd of health. SiS nc ......:..s .........I Pres . 11-29-84 ........................................ ............................... Date Application Approved By......_.. ....................... Application Disapproved for the following r::::�On -------------------------- ....Da.te.............. ......................................................................................................................................................................................................... Date PermitNo................................................... Issued ................................................... Date ` No................ ...b ............ .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. .QWN.................O F........P ARN S T'�BisE....................................................... Appliration for Disposal Works (9onstrurtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: L'at it45 ................_........_...................................................................... -•............ .................................................................................. Capricorn Re�� "�f' ex t _ Sunny Wood L�j4'�xo _ ..•............... ..�.................. ................................................ ........................................................................................7......... • Owne Address W Hyannis d :........ ..............--:... .................................... .................. .................••••• -----•••........•-•-.........----•----•••-••••••...... Ins .. Address Type of Building M Size Lot:......1.8.. 2.....Sq. feet U Dwelling—No. of Bedrooms....................3......................Expansion Attic ( ) Garbage Grinder (nc) `4 Other—T e of Building _.__...... No. of persons........................... Showers Q' � ------ ---------- ------•----....---•----- ( ) — Cafeteria ( ) Other fixtures . ............................... W Design Flow.......................5.`�........._.._...gallons per person per day. Total daily flow.._......_._.... . ....................gallons. WSeptic Tank—Liquid capacity...li� .9allons Length. !.'.:'...... Width.n.-.C-`-'_ Diameter...----......... Depth:..w�.'a... x Disposal Trench—No. .................... Widtfj.................. Total Length.................... Total leaching area................_._.sq. ft. 3 Seepage Pit No..................... Diameter.._.....L�....... Depth below inlet....5.- ...... Total leaching area....?57.....sq. ft. Z Other Distribution box ( Dosing tank ( ) '-' Percolation Test Results Performed by..._._Eldrec�aE__•Enaineerinct Date.....1OZ18184 ... Test Pit No. I.....2.........minutes per inch Depth of Test Pit..... :?......... Depth to ground water.. -Of tz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wate 04 ._......��...... ...........................................""...........�.................. ........................ .......... i. O d 0--.�� �:n �. .d �l 2 72 medium'1Description of Soil ... `O� w.. subsoil;..............•---"""-•---"""c""--""....""----..._......... n......ALL,YN_.. �+ sand and..XOClS; " '3 '�t' IiiEdium sand v WILSON W ,e 'A No.302164Q h .......................................................................................""""""-"-----•-----•""-"----""....---•"-""""------"-•............----••.......... �q UNature of Repairs or Alterations—Answer when applicable...................................................................... ...........•.................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLs✓ 5 of the State'Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hajbDeen * d brd of health. 29— t�res. il- 84 Sined .lf....."""-""-""""""-""""-""-"............."""-"""""•""""-"""- "-""""-""""""""""--"......... Date Application Approved BY 0.= .......""-"".............................. .-"""- � o-:--. ........ Date Application Disapproved for the following re ...........................•--- .:.........................": Date PermitNo.--..........................................:......---- Issued......................................................... Date i THE COMMONWEALTH OF MASSACHUSETTS 'a BOARD OF HEALTH Town..................oF......Barnstable I t .... ................................................... Trrtifiratr of Tautplinnrr ` THIS D C FY the Indi '•d al wa a Disposal System constructed ( X) or Repaired by = ........:.......•--•..•.... ............ ---_..._._........................................--•--•........................-----.......... s1 L # 4�5, Sunny Mood Lane, Hya e at..............:........••--••--•......................................._.........---....................---•••••-•-........--•...............••................................._...................... has been installed in. accordance with the provisions of TITLE5 of The State Sanitary Code as described in the - -application for Disposal Works Construction Permit No----- ................. dated............. ................................. THE + ' TyHIS CERTIFICATE SHALL NOT BE C YRUED f�►S GU E THAT THE SYSTEId 19E71 L I 4SATI•SFACTORY. DATE........--•-••........................ _ .......--••-•............... Inspector... l THE COMMONWEALTH OF MASSACHUSETTS 4, dt BOARD OF HEALTH o Twwn - Barnstable �G G ...........................................OF................................_......................................... ........... No..fj...............5-.... FEE-2................. Permission is hereby granted ..... . ..................... ................................................... to Construct ( X}Lo t Repa} 5 unny'U lual `�&�isgosal System atNo... ........... "....... •"-..ya......... Street as shown on the application for Dispos Works Construction Permit No..................... Dated...................... _:. ... -------•"•"-""""-"..............................._ Board of Health DATE....... ............................... FORM 1255 HOBBS &.WARREN. INC.. PUBLISHERS ~ REVISIONS: • ATE OF TEST/NG, C TAIL : sizE- 1 -GAL. D/ST. BOX DETAIL : LEACHING FACILITY DETAILS NO. DATE TEST P1 T DA TA � D � T � -�— P ERC. TEST DATA SEPT/C TANK DE TEST BY:,) DATE OF TESTING' of TO CONFORM TO T/TLE5REOUIREMENTS TANK TO �+ONFORM TO TITLE 5 REOU/REMENTS. T. P. i WITNESSED BY: TEST BY. J Z2 e'er'x NO. OF OUTLETS: - -- - L(] - -- -- -- ---- - —RE M OVEABLE COVER MANHOLE BROUGHT TO WITNESSED BY > a , ` - , � -_- 2"PFQ FINISH GRADE. EA TO NE LOAMaFILL I2"M/N 3'CLEAR 3 CLEARS Y �•;r- I OUTLET PIPES --- - I -- - -- r ;I . ., AS REQUIRED DEPTH OF TEST _ 6"MIN. 2 M/N• 6 M/N /NLEr-- ; II t \ -- DIST. RATE tr2�_�Y 1�1- --L t1:r ) /0 MIN — it eox , t -_ - -- INLET TEE ----- ourLEr TEE b - I 4"C I /0" (5- GAL ' 94" � /NLET AND OUTLET 4'0" MINIMUM OUTLET TEE DEPTH � �, SEPTIC TANK � ' I .. PRECAST OR BLOCW :MIN' t rEES TO BE CAST L/QUID DEPTH /4"4T L/OU/D DEPTH OF 4' 2 6 V CONCRETE / Q SEEPAGE PIT .. 5 0 / - -- -- --- — - IRON, SCHED. 40 ? 24" r a b o e "P ONS RUCTI N M N 6; C T I DEPTH OF TEST° -_-___ _ ----__-- - __- P.V.C. OR CAST IN • ' PLACE CONCRETE „ BOTTOM ON LEVEL STABLEBASE RATE' CONCRETE o. 34 B -- CONSTRUCTION --- - --- - - (WA ET TEE PRO WHERE SLOPE FOUNDATION J I• t _ --_ - --- - - - -- - - - r -- . ., ... _ .. ; . .,.. . . ... .. . . .o, o, ZOINFLIAILET PIPE EXCEEDS O.OB % OR ( - I ------- ------ I /!�E SA • CIE TANK r0 BEASLE TO WITHSTAND BOTTOM OF TANK ON LEVEL STABLE BASE H-/0 LOAD/NG UNLESSUNDER /N A PUMPED SYSTEM. 20 M/N. - I I%Y'WASHED STONE' PAVEMENT OR IN OR/VE.H-20 �- -- --- -- --- ----------- i I L OAD/NG UNDER PAVEMENT OR DRIVE. --- - —� I I t i F'4/ VER T EL E VA TIONS: NOTES : PLAN VIEW /. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION OF THE SEWAGE DISPOSAL FAC/L/T Y ONL Y. SCA L E : / "= `.i : _ qr` I,N V A T BUILDING D IN G Z 1�..____ / �`�'' M,�,SR �,• ,�,�j`��� �� ALL CONSTRUCTION METHODS AND MA TERJAL S SHALL CONFORM TO - INV. AT SEPTIC TANK(IN) _II, r!?f1Yr' �;''' 1 ' Ri:YN 2 _ --/NV ArsEPrlc rANK(GrIT) �Ir�_ . , � v�.csoro MASS. D.E.O.E. TITLE 5 AND THEF/� �vST.v� _ BOARD OF HEALTH REGULATIONS. (• , _INV. AT D/ST BOX(/N) INV AT DIST. BOX(DUT) A T L EACHING FACIL I TY ZQ J� 7 - - -__- BOSTON, MASS. WORCESTER. MASS. AT BOTTOM OF-PIT. 6457- HALIFAX, MASS. NORWELL, MASS. BEDFORD, MASS. LEXINGTON, MASS. HYANNIS, MASS. MANSFIELD, MASS. CRANSTON, R.I. DERRY, N.H. g C o , i 0 %57 O N DA TA Z_ - -�75 , DESIGN FLOW E31E11:: J REOUIRED SEPTIC TANK —499: GAL. SEPTIC TANK PROVIDED = 1 ___ GAL. CAPE COD SURVEY ,� F FA I /TY: CONSULTANTS L 0 7 �/`{ REOUIRED SIZE LEACHING C L 3261 Male Street Route 6A Barnstable Village, Massachusetts 02630 v NJ Iwo CAi.►oiQ (� - (617, 361? 8133 DIVISION OF tf i BOSTON SURVEY CONSULTANTS INC SIZE OF LEACHING FACILITY PROVIDED ENGINEERING - SURVEYING PLANNING f�'�i7PnfL 7H ?', ������ � �Lti r• •�,� TYPE OF SYSTEM, TITLE: 73.90 -- -- — —-- ---- — 7 ' A6 = �. _ ,� .. ��� - =-- SEWAGE DISPOSAL SYSTEM `-- 3 -- DESIGN - - --- lX - �,_ L OCUS PLAN �,4 f?�v� T.q�C F r- 2 0 Lv �f�y-��vi✓,S� 4 SS . FOR: /Vo TE y W D o ��'/ V'E ,�,�G� P I- ��P>QiCo� v �E,ye-=y 7'r,�r,s� -Ro pe'" ry L r,,/6'•5 s �vo W/V H�RAM c G / �' .C. C . 3128y� + Srr-� c0r 1 0� 1.�/ER� C'oml� ��D F�•40 iz,� 7 / 7" .9/✓ ' �� SCALE. AS SHOWN TG/AG S `R YLrY G�N ?"yE G rj METERS Z _ LOC,vca / 1-©T"y�' FEET 0 /G '!o (oS woo eJ DATE:o fJ R t vE COMP./DESIGN: CHECK: FR0 T //O C DRAWN: A1 C, flA TuM . ,� FIELD: 74( �: E1 S� T/N ,� '� C'.��5?C'['. L AiF' FILE NO: DWG. NO: ;;1_5-5� JOB NO: 3 - i yyr3'' .S, S10E" :fit /-.'v < _ SHEET: I OF: