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0046 SUNNY-WOOD DRIVE - Health
46 SUNNYWOOD DRIVE, HYANNIS A = 273 218 a, � o 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sunny Wood Drive, Hyannis, MA Property Address Barbra A. Carr Owner Owner's Name information is required for 46 Sunny Wood Drive, Centervill-Hyannis MA 02�632 03/27/2009 every page. Cityrrown State Zips 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. 'mp°rta"When fitting out A. General Information forms on the 614 �_/3�computer,use 1. Inspector e I only the tab key l to move your Reid C. Ellis ! cursor-do not Name of Inspector ! use the return key. Ellis Brothers Const. I Company Name VTk:ZA 23 Enterprise Road, P.O.Box 59 Company Address Yarmouth Port, MA 02675 Citylrown State ! Zip Code 508-362-6237 S121891 Telephone Number License Number B. Certification ! I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 16.340 of Title;7 CMR 15.000).The system: I r; Passes ❑ Conditionally Passes ❑ a F ils N ❑ Needs Further Evaluation by the Local Approving Authority zn —j co Inspectors Signature Date q M The system inspector shall submit a copy of this inspection report to the Ap iroving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the,approving authority. '"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 6 Official inspection Form:SubsiaFaos Sewage Disposal System•Page 1 or 17 Commonwealth of Massachusetts Title 5 :Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sunny Wood Drive Centerville-Hyannis. MA Property Address Barbra A..Carr Owner Owner's Name information is 46 Sunny:Wood Drive, Centervill-Hyannis MA 02632 03/27/2009 required for every page. city/rown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: i ❑ 1 have not found any Information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as descri ed in the"Conditional Pass"section need to be replaced or repaired.The system, upon cor ipletion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determine("(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 infiltra Jon or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replac ad with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is tructurally 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 bc low): t5irl•09= Title 5 tnfioial Inspection Form Subsafaoe sewage Disposal system•Page 2 of 17 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sunny Wood Drive, Centerville-Hyannis, MA Property Address Barbra A. Carr owner Owners Name information is required for 46 Sunny Wood Drive, Centervill-Hyannis MA 02632 03/27/2009 every page. City/Town state Zip Code Date of Inspection B. Ceftification (cont.) B) System Conditionally Passes(cunt.): ❑ Observation of sewage backup or break out o high static water level in the distribution box due to broken or obstructed pipe(s)or due to a brc ken, settled or uneven distribution box. System will pass inspection if(with approval of Board ofHealth): ❑ 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 tin es a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval o the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further:Evaluation is Required by the Boa o Health: ❑ Conditions exist which require further evaluatio by the Board of Health in order to determine if the system is failing to protect public health, sa ty 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 functionii ig in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a urface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09= Title 5 OffcW tnspeOw Fart[SO=faw Sewage Disposal System•Pow 3 of 17 , commonwealth of Massachusetts Title 5 Official Inspection Form: Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 46 Sunny Wood Drive,Centerville-H annis , MA Property Address Barbra A. Carr Owner owner's Name information is 46 Sunny Wood Drive, Centervill-Hyannis MA 02632 03/27/2009 required for State Zip Code Date of Inspection every page. cityrrown B. Certification (cunt.) 2. System will fail unless the Board of I ilealth(and Public Water Supplier,If any) determines that the system is functions ig 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 tribut 3ry 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 an J 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 analys , performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.°.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El than depth in cesspool is less than 6"below invert or available volume is less than %day flow Title 5 Olfidel hspecti in:on Fra Soadace Sewage Disposal System•Page 4 of 17 Mina•119R18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 Sunny Wood Drive,Centerville-H annis, MA Property Address Barbra A.Carr Owner Owner's Name information 46 Sunny Wood Drive ill-Hyannis MA 02632 03/27/2009 required for 46 Sun Sate Zip Code Date of Inspection every page. B. Certification (cont.) Yes No . ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered:A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- I o,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 contactte Board of Health to determine what will be necessary to correct the fails 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 ay "or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 t of a surface drinking water supply ❑ ❑ the system is within 200 eet of a tributary to a surface drinking water supply ❑ ❑ the system is located in nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapp Zone 11 of a public water supply well If you have answered°yes°to any question in ection E the system is considered a significant threat, or answered"yes"in Section D above the larg 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. Title 5 o(riad hspW=Forvr Subsufaoe Sewage Disposal System•Page 5 of V tsina•09= Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sunny Wood Drive, Centerville-H annis, MA Property Address Barbra A.Carr kir Owner Owner's Name information is 46 Sunny Wood Drive, Centervill-Hyannis MA 02632 03/27/2009 required for state Zip Code Date of Inspection every page. cityrrown C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ [� Were any of the system components pumped out:in the;previous two weeks? ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ this inspection? El available as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components,Mcluding the SAS; located on site? ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? El information the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms.(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): TO 5 Offi"WoPeWOn FO=&bwhm Sewage Disposal System Page 6 of 17 Wins•0%W commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sunny Wood Drive,Centerville-H yannis, MA Property Address Barbra A. Carr Owner Owner's Name information is 46 Sunny Wood Drive, Centervill-Hyannis MA 02632 03I27/2009 required for State Zip Code Date of Inspection every page. cltyrrown D. System Information Description: l Number of current residents: Yes Does residence have a garbage grinder? ❑ Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes N Laundry system inspected? ❑ Yes N ❑ Yes No Seasonal use? Water meter readings, if available(last 2 years usage(gpd)): Detail: 07 � � k -7,S 0',3, .25 ❑ Yes No Sump pump? j=_2_6 __10f Last date of occupancy: Date CommemiaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.fL,et .): El Yes ❑ No Grease trap present? Yes No Industrial waste holding tank present? ❑ ❑ y ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 s stem? Water meter readings, if available: Title 5 official Inspection Form-Subsurrace Sewage Disposal system•Pegs 7 of 17 t5ins•09M Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sunny Wood Drive,Centenrille-H annis, MA Property Address Barbra A. Carr Owner Owner's Name information is 46 Sunny Wood Drive,Centenrill-Hyannis MA 02632 03127/2009 required for State Zip Code Date of inspection every page. Cityfrown D. System Information (cont.) IAI Last date of occupancy/use: Date Other(describe below): General Information ,3VA„✓ew llv Pumping Records: G Source of information: � Was system pumped as part of the inspection? ❑ Yes 2. /No If yes,volume pumped: gallons i , Al How was quantity pumped determined? Reason for pumping: Type of System: pL� Septic tank, distribution box, soil absorption system ❑ Single cesspool [J 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): Title 5 official Umped'on Form:Subsurfew Sewage Disposal System•Page 8 of V tsins•0901 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . ' 46 Sunny Wood Drive, Centerville-H annis,MA Property Address Barbra A. Carr Owner Owner's Name information is 46 Sunny Wood Drive,Centervill-Hyannis MA 02632 03/27/2009 required for State Zip Code Date of Inspection every page. Crtyrrown D. System Information (cost.) Approximate age of all components,date installed(if known)and source of information: Zs— Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): ! �� Depth below grade: feet Material of constructioV40 cast iron PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.):. � � Al /V 72'� ee" �fU Septic Tank(locate on site plan): Depth below grade: feet Material of construction: [concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is me4l, fist age: I years ' Yes ❑ No Is age confirmed by a Certificate of Compliance?(attach a copy of Certificate es / Dimensions: Sludge depth: Title 5 Official Inspection Form Subsurface Sewage Disposal SyStern•Page 9 of 17, t5ins•09= Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sunny Wood Drive,Centerville-Hyannis, MA Property Address Barbra A.Carr Owner Owner's Name information is required for 46 Sunny Wood Drive, Centervill-Hyannis MA 02632 03/27/2009 every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ' AA1.�G✓/nl ,S-Ck.� INIL,� �+z c'/ e/�,t.C A 4' All Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fi erglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee oi baffle Distance from bottom of scum to bottom of outl t tee or baffle Date of last pumping: Date Title 5 Official kmPectim Form:8.0%dace Sewage Disposal System-Page 10 of 17 t5irrs-0910H Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sunny Wood Drive, Centerville-H annis, MA Property Address Barbra A. Carr Owner Owners Name information is 46 Sunny Wood Drive Centervill-Hyannis MA 02632 03/27/2009 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cunt.) �� Comments(on pumping recommendations, inle and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence f leakage, etc.): i Tight or Holding Tank(tank must be pumpedolit time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal 5berglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float swit hes, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Title 5 WOW bvMactim Fmm subsurrace sewage Disposal ern Peae 11 d W t5ins.09= Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sunny Wood Drive,Centerville-Hyannis, MA Property Address Barbra A. Carr Owner Owner's Name information is 46 Sunny Wood Drive, Centervill-Hyannis MA 02632 03/27/2009 required for every page- City/Town State Zip Code Date of Inspection I D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): �✓J Ay,,�� 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.): ti _ l � ell f j k ' E Pump Chamber(locate on sit 3 plan): Pumps in working order: ❑ Yes ❑ No t Alarms in working order. ❑ Yes ❑ No j P Comments(note condition of ump chamt er,condition of pumps and appurtenances, etc.): P Soil Absorption System(SAS)(locate on site plan, excavation not:required): If SAS not located,explain why: P P We 5 OffidW hispection Form:&bwfaw Sewage OrV=W System•Page 12 of 17 t5ins.09108 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sunny Wood Drive, Centerville-Hyannis, MA Property Address Barbra A. Carr Owner Owner's Name information is required for 46 Sunny Wood Drive, Centervill-Hyannis MA 02632 03/27/2009 every page. Citylrown State Zip Code Date.'of Inspection D. System Information (cunt.) Type: leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, et&V ' If < 7: IP —n�a V— C&4pools(cesspool must be pump as art of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑. Yes ❑ No t5ins•09M Trtie 5 official hmpection Fam:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 46 Sunny Wood Drive, Centerville-Hyannis, MA Property Address Barbra A. Carr Owner Owner's Name information is 46 Sunny Wood Drive, Centervill-Hyannis MA 02632 03/27/2009 every veryrequired for page. City/Town state Zip Code Date of Inspection e D. System Information (cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): I Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of by Iraulic failure, level of ponding, condition of vegetation, etc.): I I t51ns-osm Title 5 of ciW trspedim Forth:Su mcfaae Sewage Umposat System'Pegg 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sunny Wood Drive, Centerville-Hyannis, MA Property Address Barbra A. Carr Owner Owner's Name information is required for 46 Sunny Wood Drive, Centervill-Hyannis MA 02632 03/27/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately Wf Imo . B� } .33 6 i tsirts-09= rdle s olficud hwacbon Form:subsiuface Sewage Disposal system•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sunny Wood Drive, Centerville-Hyannis, MA Property Address Barbra A.'Carr Owner Owner's Name information is required for 46 Sunny Wood Drive, Centervill-Hyannis MA 02632 03/27/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells t� 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: Dace ❑ 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 h w you established the high ground water elevation: ��/'✓ 6j ,volw 57 �-7zz Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5-ft-09W Title 5 Official brspection Fomr.Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sunny Wood Drive, Centerville-Hyannis, MA Property Address Barbra A. Carr Owner owner's Name information is required for 46 Sunny Wood Drive, Center%ill-Hyannis MA 02632 03/27/2009 every page. C4rrown State Zip Code Date of Inspection E. ;Inspection rt Completeness Checklist Summary:A, B, C, D,or E checked inspection Summary D(System Failure Criteria Applicable to All Systems)completed LJ 5 tem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5m•03W T-Ma 5 Offidal Inspection Fome Subsurface Sewage Disposal System•Page 17 of 17 l,• �'� 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION rORM Address of property r/6 Suti i., y woo J Ny� �h� S , X4 _ Owner's name AN�vK Fe- rr�.-� • Date of Inspection y PART A CHECKLIST Chec if the following have been done: 7Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if the are not available with N/A. y The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. / V The septic tank manholes were uncovered, opened, and the. interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of / sludge, depth of scum. . y The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of' SSDS. SUBSURFACE SEEPAGE DISPOSAL SYSTEM 'INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 2 number of bedrooms D number of current residents garbage grinder, yes or no' YES laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information: �A O L L D y-d C OL 41 s A/0 System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Ty p 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: , - 9,,�, s4- 6 /r ZO.N A/4 Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / SYSTEM- INFORMATION continued SEPTIC TANK: y (locate on site plan) depth below grade: / 'y // material of construction: concrete metal FRP other(explain) dimensions• X q X �0 00 C3 C, sludge depth 1 ,6 ' distance from top of sludge to bottom of outlet tee or baffle scum thickness distance from top of scum to top of outlet tee or baffle I 'Y•' 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/1--of leakage, recommendations for repairs, etc. ) --LL d L. rGTG C G O In o f t - 0.k d PVC t O 1 In �L T c�J� y1 A r i 0 k i G t n d a j . P c d lam-, i., ,, d, G)U van .�•h o, cTL� a. N C- jig DISTRIBUTION BOX: _z (locate on site plan) le- depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or o}�t of b,Ax, recommendation for rep irs, etc.) J2— /3o,,C -�' .� � a , 2.✓.c / (/ ! .'� l'o? U S �a G�✓o. � G�C-t !M - A�v 'G_J � � C �. c e a 7C 13, C cn v�f/'4� O ✓ 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 FORK PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits and number leaching chambers and number 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, conditio of vegetation, recommendations for maintenance or repairs,etc. ) dA C o CESSPOOLS (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 (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: 119 (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 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' r ON, 5 029' 6 0 �A^µ JS'6,, 36 1 0-6o)e Ga' LP; w a1N� . DEPTH TO GROUNDWATER depth to groundwater method /of // determination or�/appr/oximation: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 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? A/ Discharge or ponding of effluent to the surface of the ground or surface waters? /y Static liquid level in the distribution box above outlet invert? N� Liquid depth in cesspool <6" below .invert or available volume<. 1/2 da}- flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? I/ within 50 feet of a surface water? Al within 100 feet of a surface water supply or tributary to a surface water supply? Al within a Zone I of a public well? V 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 analy;, for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector y I w+5 Company Name �G / �; �; �, s J�� 5 4 S Company Address 410 Q l cl g,s 3 Wiu c r 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. !21"1 one: 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 y6 Sot^&, w (4 i d L " L0CAT.IO-N:' 4 #� b SEWAGE PERMIT N0. - �� YILLAG. E .: JN INSTA .L::. S NAME A ADDRESS K :` VA \CK E.` `s U I L D E,.R 0R' OWN ER DATE PERMIT ISSUED 3 DAT E C:O-.MPLIANCE ISSUED g a -------------- B�9 c o : :....1 3 TOWN OF BARNSTABLE / LOCATION Sc�n n f�eye�r p SEWAGE# VILLAGE Ceg I— /1£, nnvf ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO.f vlS f0l-16'1 El!I S /3Q, ' I SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS 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 77 t loll: LN \ g a a a7 3 -0718 LO CATION °' '#�® SEWAGE PERMIT NO. VILLAGE � INSTALLER'S NAME & ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED 3 0 DAT E COMPLIANCE ISSUED C-j ryl rn I J No........ .4- 10q5 Fim....r2)................. ....... ...... ........ THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH TCM ...........................................OF.......BAPNSTABIE ................................................................................... Appliration for Dispaiial Varkg Tonstrurtion ramit Application is hereby made for a Permit to Construct (X ) or Repair an Individual Sewage Disposal System at: Lot 29 .............................................................................................. ...................................................W........................................... L.Qcation-Address or Lot 0 Capricorn Realty Wood Lane ............................... .......... .... ... .............. ....................................................... .........***----------- ......**'*'*----------------- W..r Address ............... ...... .............................................................................. ............ .....................................,�r Installer Address 15 000 Type of Building. Size-Lot.............................Sq. feet Dwelling—No. of Bedrooms...... .....................................Expansion Attic -Garbage Grinder PO) Other—Type of Building .............................No. of persons............................. Showers Cafeteria P4Other xtures ............................................................. ......................................................... < 330 Design Flow............................... gallons per person er q�y. Total�ailj flpw....................*........*..............gallons. Septic Tank—Liquid ............gallons Length..... -6 5"-4 W ........... Width........z....... Diameter................ Depth................ Disposal Trench—No. .................... Width..............._._.. Total Length.....................Total leaching area....................sq. f t. Seepage Pit No..................... Diameter...1.0............. Depth below inlet---5..67........ Total leaching area....2.5.7.......sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by.......Udredge..2agimeerimg................... Date....... 0Test Pit No. I.....?...._._.minutes per inch Depth of Test Pit......12........... Depth to ground w OF, 44 Test Pit No. 2................minutes per inch Depth of Test Pit___................. Depth to ground .... .... "MOR - P4 ........................................................................................................*--------*........ --AttYW-- 0 Description of Soil...P.-;�4",.J ..and subsoil;...;�4"-72" bony medium sand; 72 -144" ��ium sand..................... .....................I.......................................... w�-----WIL-SG14- ....................................................................................................................:................................................ W. ......................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................... -NA ................................................................................................................................................................. ........ Agreement: �/Ir_ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE Ti 1E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance een issuejLb the board of health. ee'Signed..... .. Pres. 11-29-84 Date 0 ------------------------------------------ --------- Application Approved By................. "0 40 .,mg!f�_Pe. ............. ...... ............................I.......... Date Application Disapproved for the following real s:.................................................................................................................. ......................................................................................................................................................................:.................................. Date PermitNo......................................................... Issued-...------------------------....................._...... 7 Date No....—10 q� Fss..... 6"/.......... i' .THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tq.14.........................OF....... Ili`IS1': F......................._-.:. ........................ Appliratiun for Di ipoii al Works Tonstratr#ion Prrmi# Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: (L " lot '19 .................•___-....»...................................................................... ......................___......................................................................... Location-Address or Lot No. im-_RM -- us t ............. >r?.'�z?v..j°? .. •�...................................................................................... n Address -•,. pq Installer Address UType of Building Size Lot...15.r 0().0..__......Sq. feet Dwelling—No. of Bedrooms____3.......... Expansion Attic..............:........ p ( ) -Garbage Grinder (110) `-1 Other—Type T e of Building ....__, No. of persons............................ Showers a YP g -----.....-•-------. P ( ) — Cafeteria ( ) W Other fixtures ---•••......•..........•---•-•-- - W Design Flow, ............`�.....................�0 0--gallons per person per day. Total daily,.floow.._....__.-33�•.._________..._.______..gallons. WSeptic Tank—Liquid capacity.::.__...__gallons Length.......:........ Width__. .....ig. Diameter___............. Depth..T.......... x Disposal Trench-No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........1........ Diameter...10..._.__..... Depth below inlet...5a67....... Total leaching area....2`7.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by.__....ELI �i;n..l�?g — .................. Date..__ /�.� Test Pit No. 1......2.......minutes per inch Depth of Test Pit.....12.......... Depth to ground water OFA�,� rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wat R+' -•-•------••----•...................................•••-----•-•-......._...---------................--•-••••---••--------•-••... TEPHEN S �' ------AE1YN•-- �n D Description of Soil....�3- �?`.'.�..IAk ..3iS ..:?�1�? G. l.;...c?Q"- "__t�QX1 ..iili�?1 ?1---------•-•-••- rye ...--•-----------------------------------•--------------------------•------. ---------------------------------------------------------•-----------------•--••• 9�,r his U Nature of Repairs or Alterations—Answer when applicable......................................................................... Agreement: cwie _ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance wit 6 the provisions of TIT12 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Complianc a e��__i__s11 by the board of health. t/V% :0 Sined._................ --•-•-----•---------------------•••••-----•i'rlr......---- .... 11-29—$4• .... Date Ap lication Approved B •----•..... .: f__ ............. P PP Y•---•---------- � Date Application Disapproved for the following reasons---------------••-•-----•---••-•-•-----•------------•---•-----•------------------._.........•-••-.......!....._ i Date PermitNo......................................................... Issued.......................-=-----------•------7----•-•----- Date THE COMMONWEALTH OF MASSACHUSETTS • iii' " BOARD OF HEALTH 4 ..........Town.......?...........OF.....Barn;eta DI P.......................................:........ Trr#iflta#r of Totttpiiaurr _ •r`' "n,„, RTIFY, T the Individ"eAr, Disposal S�+stem constructed (}� ) or Repairedbel �................. ••-------•------....-•-•-------...---•._._.................••••-•-.........--•••.._._.._..... at Lgt 29,> Sunny Flydood...Lane Hyannis.............................................................................................. ep has been installed in accordance with the provisions of TO, F of The State Sanitary Cc�dei s des fabe� the application for Disposal Works Construction Permit No.__...............✓.1 ............... dated__..-r_.:...i._........._.._._.__.__..__.___... THE ISSUANCE OF THIS CERTIFICATE- SHALL NOT BE CONS RUE® AS G ANT E THAT THE ._'. SYSTEM WILL � 10 SATISFACTORY.1 DATE....................: .........:........`........................................ Inspector....----------- •..__--•-...•--•--•-----•------•--•-••-•----••--•--•-•............. r'^ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,• ,y-ice j Barnsta1ble.............. ............................s' .................... p. i9Permission is hereby granted ._....-•---1 = to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at No._--•-•-Lot---#---a9.......gun--..Aood...Lane -_Hyannis---------------------------•- Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... •---•---•--------•-- -...'Z-• ----•- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 36 REVISIONS: A : DATE IF TESTING �`' __ _� =y� _ PERC. TEST DATA SEPT/C TANK DETAIL s�zE- _ � �_ _ GAL. DIST. BOX DETAIL : LEACHING FACILITY DETAIL: NO DATE TES T Pl T DA T TEST BY., >� � ! DATE OF TESTING _�_OI-/ 9�' TgNK TO CONFORM TO TITLE 5 REOUIREMENrS. TO CONFORM TO T/TLE 5 REOUiREMENTS { T. P. 7 WITNESSED BY: moo, 'C�� � _- TEST BYl _ NO. OF OUTLETS r ----- -� _�- _ ----- - -- -- _ - REMOEBLE COVER BY 0m l2 MANHOLE BROUGHT TO FINISH GRADE. 2"PEASTONE LOAMaFILL /2"MIN. If .,• 1=.. , .♦ O > —� �� a V' — S 3 CL AR. . . 3 CLEAR' . ---i - - t Ir- I OUTLET PIPES 'e --- - 6'M/N. 8 . 6„MIN �` ii 45REOUIRED\ DEPTH OF TEST -- `� ' ©/V y -- - - --- _ _ -. di - RATE 2 M//V /MC H '9 5S U w�' INLET ( ` I aox -- DIST. /NLEr TEE -- /D"M/N. >'—OUTLET TEE _�� / _ (� ./ i „ i 4 C./. 0' "_ GAL. 14'r I - - - - - i o . NLEr AND OUTLET 4'-0" MINIMUM . - 0U FL ET TEE DEPTH /4"AT LIOU/D DEPTH OF 4' :, 2 6" SEPTIC TANK i . PRECAST OR BLACK •M/l�!' F TEES TO BE CAST L IOU/D DEPTH /" CONCRETE SEEPAGE PIT IRON, SCNED. 40 °-, CONSTRUCT/ON DEPTH OF TEST — -- --- PVC. OR CAsr/N 249 „ �' MIN ' PLACE CONCRETE CONCRETE , RATE 34'" " B' BOTTOM ON LEVEL STABLE BASE ---- _ - - - -- CONSTRUCT/ON . _- - % (WATERTIGHT)- - - -- -- r I / FOUNDAT/ON i, ' .•�INLET TEE PROVIDED WHERE SLOPE - S OF INLET PIPE EXCEEDS O.OB % OR , I ' ,yE TANK TO BEAGLE TO WITHSTAND - /N A PUMPED SYSTEM. 20 MINBOTTOM OF TANK ON LEVEL STABLE BASE H-/0LOADING UNLESSUNDER _- __T! / -- ----- — -- -- ------ --- -- -- - _ -- ----- l/2' WASHED STONE i PAVEMENT OR/N DRIVE.H-20 � I LOAD/NG UNDER PAVEMENT OR DRIVE. /► —r-�/"L.7 J - ---- — — W. G NO TES : PLAN V/EW : /N VER T ELEVA TONS: /. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION OF THE SEWAGE • DISPOSAL FAC/L/T Y ONL Y. SCALE / "_ ='�, ' " -i.� or _ INV. AT BUILDING C B.SQ -- �''r`�m's � 2 ALL CONSTRUCTION METHODS AND MATERIALS SHALL CONFORM TO —/NV. AT SEPT/C TANK(/N1 v � 1 sALL'V�r� MASS. D.E.Q.E. T/TLE 5 AND THE ?f�' ., BOARD OF _ -- � -- ia� K ALiY�1 /NV. ATSEPric rANK(G!'JT> � _�_� _ _ -, HEALTH REGULATIONS. � • wu �, . �4 i WILSON 10 �•-' ?Ica. 1`d$$i <, 3 TU ei 4h 1 o iih/(.S 4-4;7- g/3.° �►IS14. / ' �O �(�Tf� __.. __INV. AT DIST. BOX(/N) P3 "p? INV. AT DIST. BOX(OUT ii�,%7 7 -94 AT LEACHING FACILITY: 7 27 BOSTON, MASS.=- AT BOTTOM OFPIT ' HAL FAX, MASS. NORWELL, MASS. MASS. I BEDFORD, MASS. LEXINGTON, MASS. HYANNIS, MASS. MANSFIELD, MASS. CRANSTON, R.I. DERRY, N.H. , g C S -PESIGN DATA DESIGN FLOW 33© iH p.G NO E3 !E; ll:: f r REQU/RED SEPTIC TANK /V /2 - s7- 20 E / -- — — I '�-� 7^- �'� ..�- -- .� �I ,, - SEPTIC TANK PROVIDED = /.�d©a GAL, CAPE COD SURVEY CONSULTANTS �' Q @� REQUIRED SIZE LEACHING FACILITY ,� ,� -- --_ ----_. 326" Main Street Route 6A --- _ Barnstable Viitage Massachusetts 02630 DIVISION OF a a/I t BOSTON SURVEY CONSULTANTS INC SIZE OF LEACHING FACILITYPROV/DED ENGINEERING SURVEYING PLANNING t. O 7" 3 p - ` TYPE OF SYSTEM TITLE. yEyvrlt,L_ /263.:?tE�7_1c ,�? �_= - . \ - - r7VZ�l LJ S1S"N /.C?-_�2_'�',G? S ?4 Gr'G Q W ,'UOC� ��:_.4w , -�� r -----+_ 9 SEWAGE DISPOSAL SYSTEM DESIGN f LOCUS PLAN oleo— FOR: a ;- _ L' Af'JY/G'ca'I .•Y f'E.4[ T c o kv It �"''� c' SCALE AS SHOWN � N �'.�NE F'DN .`t/ r'E � /o W !`_ ',�� �'(�I'Y)�/LE�.'� /C"/ 'D�? d. C�'.C', .3zc3 `�'9 -9nVo nr> s '�,:' 11 ME,ERS G OCR.., o T z 9 FEET 0 Env sc„y,vywar,p DATE: �011V16 ��;�� pP COMP./DESIGN: �f' �. sr s,. .w. �'"T.B,9Ck.S cl SC'.11t_F l'�f_ e` CHECK: k/'rri: / �. A, F 0,,V 7- 3,0 TUM� �.DA� jS E'D //O C DRAWN: J,� FIELD: 11V ;;'41 7Z'W,-,V D r. FILE NO: T 01v TEE- S _ ..�,t..=. DWG. NO: JOB NO: p.3- f !ci 7 �..f_ f '.,, / 2_ SHEET: I OF: