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Commonwealth of Massachusetts age-::�-
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PCK LLC
Owner Owner's Name
information is required for every Hyannis Port ✓ Ma 02601 3/30/21
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 610 1 Sam
on the computer, Michael DiBuono
use only the tab
key to move your Name of Inspector
cursor-do not DiBuono Sewer And Drain
use the return Company Name
key.
35 Content Ln
Co
Company Address
Cotuit Ma 02635
City/Town State Zip Code
508-364-9587 S113522
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
4/1/21
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
I p Y p
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.7/2612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
In. 01
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PICK LLC
Owner Owner's Name
information is required for every y H annis Port Ma 02601 3/30/21
page. City/Town 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 system is functioning as designed with no sign of failure.
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
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PICK LLC
Owner Owner's Name
information is required for every �H annis Port Ma 02601 3/30/21
page. City/Town 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:
I
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
. Commonwealth of Massachusetts
J. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PCK LLC
Owner Owner's Name
information is required for every Hyannis Port Ma 02601 3/30/21
page. City/Town 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
❑ ® 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 118
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PCK LLC
Owner Owner's Name
information is required for every Hyannis Port Ma 02601 3/30/21
page. CitylTown 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 11 of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PCK LLC
Owner Owner's Name
information is required for every Hyannis Port Ma 02601 3/30/21
page. Cityrrown 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)]
f
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PICK LLC
Owner Owner's Name
information is required for every �Hyannis Port Ma 02601 3/30/21
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
Number of current residents: 2
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: Date
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
M Q Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,. 90 Wachussett ave
Property Address
WACHUSETT PICK LLC
Owner Owner's Name
information is required for every Hyannis Port Ma 02601 3/30/21
page. City/Town 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: Not provided
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PICK LLC
Owner Owner's Name
information is required for every Hyannis Port Ma 02601 3/30/21
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:
New leach field in 2012
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: 3.5
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.):
System is vented at the roof line
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PCK LLC
Owner Owner's Name
information is required for every Hyannis Port Ma 02601 3/30/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
30"
How were dimensions determined? Tape Measure/Data On File
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
No pumping recommendation at time of inspection.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PCK LLC
Owner Owner's Name
information is required for every Hyannis Port Ma 02601 3/30/21
page. City/Town 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.7126/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PCK LLC
Owner Owner's Name
information is required for every Hyannis Port Ma 02601 3/30/21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"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 Level with no signs of failure
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.):
t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PCK LLC
Owner Owner's Name
information is required for every Hyannis Port Ma 02601 3/30/21
page. City/Town 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 ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 14.5'x 25'
❑ 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I" Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PCK LLC
Owner Owner's Name
information is required for every Hyannis Port Ma 02601 3/30/21
page. Cityrrown 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.):
No sign of failure. Plastic H2O Arc 36 Chambers. 14.5'x 25'
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.):
I
t5insp.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
M 90 Wachussett ave
mil.!
Property Address
WACHUSETT PCK LLC
Owner Owners Name
information is required for every Hyannis Port Ma 02601 3/30/21
page. City/Town 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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PCK LLC
Owner Owner's Name
information is Hyannis Port Ma 02601 3/30/21
required for every y
page. Cityrrown 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
t5insp.dod•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
, r
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PERMIT DATE: S
" G COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility lb HAa emu► r,�,(
Private Water Supply Well and Leaching Facility�f an --____Feet
site or within 200 feet of leaching facility)
facili y wells exist on
Edge of Wetland and Leaching Facility(If ~ Feet
300 feet of leaching facility) wetlands exist within Q
FURNISHED Y , _r t Feet
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Commonwealth of Massachusetts
U0
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 90 Wachussett ave
Property Address
WACHUSETT PCK LLC
Owner Owners Name
information is required for every Hyannis Port Ma 02601 3/30/21
page. Cityr own 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: NGE 120"
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: 5/10/2012
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:
Test Hole Data on plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7126/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Iu; m
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Wachussett ave
Property Address
WACHUSETT PCK LLC
Owner Owner's Name
information is required for every Hyannis Port Ma 02601 3/30/21
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.
I
❑ 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
t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Wachusett Avenue Hyannis port M-287 P-84
Property Address
Thomas&Susan Dudley ='a
Owner Owner's Name
information is
required for every P.O. Box 426, Hyannisport MA 02647 March 8, 2018x:i
page. City/Town State Zip Code Date of Inspection :
Inspection results must be submitted on this form. Inspection forms may not be alteredi,n any
way. Please see completeness checklist at the end of the form.
Important:When
filling out forms A. General Information 1,2�$
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Troy Williams
use the return Name of Inspector
key. Troy Williams Septic Inspections
" Company Name
19 Hummel Drive
Company Address
South Dennis MA 02660
Citylrown State Zip Code
(508) 385- 1300 S1682
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
March 8, 2018
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
F
• ' e r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Wachusett Avenue, Hyannisport M-287 P-84
Property Address
Thomas&Susan Dudley
Owner Owners Name
information is p O. Box 426 His ort MA 02647 March 8, 2018
required for every , yannp
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipes,
components or the future structural integrity of said components and only represents conditions found
at the time of inspection only.
B) System Conditionally Passes:
❑ Ong 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 FIND (Explain below):
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17
i
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 90 Wachusett Avenue, Hyannisport M-287 P-84
Property Address
Thomas&Susan Dudley
Owner Owner's Name
information is required for every P.O. Box 426, Hyannisport MA 02647 March 8, 2018
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational.'System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
r
❑ 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):
i
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50.feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Wachusett Avenue, Hyannisport M-287 P-84
Property Address
Thomas&Susan Dudley
Owner Owner's Name
information is P.O. Box 426, Hyannisport MA 02647 March 8, 2018
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
'2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and.the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
i
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
El clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
90 Wachusett Avenue, Hyannisport M -287 P-84
Property Address
Thomas&Susan Dudley
Owner Owner's Name
information is p
required for every p O. Box 426, Hyannis port MA 02647 March 8, 2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed: The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 01 90 Wachusett Avenue, Hyannisport M-287 P-84
Property Address
Thomas&Susan Dudley
Owner Owner's Name
information is required for every Box y
p O. B 426, H annisport MA 02647 March 8, 2018
page. City/Town Ci /Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
' ® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 90 Wachusett Avenue, Hyannisport M -287 P-84 _
Property Address
Thomas&Susan Dudley
Owner Owner's Name
information isequired or every P.O. BOX 426 H yannisport MA 02647 March 8, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
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 ears usage d 17=65,000 gals.
g ( y g (gp )) 16=63,000 gals.
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): N/A
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: N/A
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M ••'' 90 Wachusett Avenue, Hyannisport M -287 P-84
Property Address
Thomas&Susan Dudley
Owner Owner's Name
information is P.O. Box 426, Hyannisport MA 02647 March 8, 2018
required for every —
oage. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: N/ADate
Other(describe below):
NIA
General Information
Pumping Records:
Source of information: No pumping info available.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Wachusett Avenue Hyannisport M -287 P-84
Property Address
Thomas&Susan Dudley
Owner Owner's Name
information is required for every P.O. Box 426, Hyannisport MA 02647 March 8, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
D-box and leaching were installed to existing tank from 1994 on 6/6/12 per compliance. _
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
18"+
p g 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.):
Lines were found clear at the time of inspection.
Septic Tank(locate on site plan):
Depth below grade: e'ewith riser to grade
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: 6'X10.5'X6' 1500 gallon
Sludge depth: 4"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
GSM , 90 Wachusett Avenue, Hyannisport - M-287 P-84
Property Address
Thomas& Susan Dudley
Owner Owner's Name
information is required for every P.O.p O. Box 426, Hyannis port MA 02647 March 8, 2018
_—
Cit /Town State Zip Code Date of Inspection
page. Y P P
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
2'8"
Scum thickness thin layer
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? probe/measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pvc inlet and outlet tees were found present and in working order. No evidence of leakage or damage
was found. Tank was not in need of pumping at this time.
Grease Trap(locate on site plan):
Depth below grade: N/Afeet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 90 Wachusett Avenue, Hyannisport M -287 P-84 _
Property Address
Thomas&Susan Dudley
Owner Owner's Name
information is
re wired for every P.O. Box 426 H yannisport MA 02647 March 8, 2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A ------
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions:
Capacity: N/A
gallons
Design Flow: N/A
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order: ❑ Yes ❑ No
Date of last pumping: N/A
Date
Comments(condition of alarm and float switches, etc.):
N/A
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments
° .� 90 Wachusett Avenue, Hyannisport M-287 P-84
Property Address
Thomas&Susan Dudley .
Owner Owner's Name
information is required for everyBox yann P.O.p O. B 426, Hisp ort MA 02647 March 8, 2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box if resent must be opened) locate on site plan):
( P P ) ( P )
Depth of liquid level above outlet invert level
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was found level and in working order with equal distribution to outlet lines. No evidence of solid
carry-over or backup in the past was found at the time of inspection.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 90 Wachusett Avenue, Hyannisport M -287 P-84 _
Property Address
Thomas&Susan Dudley
Owner Owner's Name
information is p O. Box 426, Hyannis ort MA 02647 March 8, 2018
required for every p —
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 25-ARC 36HC
biodiffusers
❑ leaching galleries number: 25'X 14'X 10.75'
❑ leaching trenches number, length: —
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system j
Type/name of technology: --
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No evidence of hydraulic failure or problems in the past were found at the time of inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A _
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form: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
90 Wachusett Avenue, Hyannisport M -287 P-84
Property Address
Thomas&Susan Dudley
Owner Owner's Name
information is required for every Box yann p O. B 426, Hisp ort MA 02647 March 8, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Privy(locate on site plan):
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Wachusett Avenue, Hyannisport M -287 P-84
Property Address
Thomas&Susan Dudley
Owner Owner's Name
information is required for every p O. Box 426, Hyannisport MA 02647 March 8, 2018
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
I i
I �
I
�ro V%k,
02
3
3 - 95 '
, 5
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 90 Wachusett Avenue, Hyannisport M-287 P-84
Property Address
Thomas&Susan Dudley
Owner Owner's Name
information is required for every y p p O. Box 426, H annis ort MA 02647 March 8, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 10.0'+
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: 5/25/12
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:
MIW 29 Zone A 6.6' .6'adjustment
You must describe how you established the high ground water elevation:
Test hole recorded on plan showed no water found at 10.0'. Groundwater adjustment at the time of
inspection was .6'. Bottom of leaching at 4.5'was found not to be located in the high groundwater
elevation at the time of inspection.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•3M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Wachusett Avenue Hyannisport M -287 P-84
Property Address
Thomas&Susan Dudley
Owner Owner's Name
information is required O. B 426, Hyannis port MA 02647 March 8, 2018
requiredd for every Box yannp —
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D(System Failure Criteria Applicable to All Systems) completed
E System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BAMSTABLE
LOCATION T() y0.C_J.1o3 Ep TT A - SEWAGE# Zolx- ly 5
VILLAGE flveninr ASSESSOR'S MAP&PARCELa
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY..(type).? ARCj�HC lJ-atA (size)
)
NO.OF BEDROOMS
OWNER =
PERMIT DATE. f � �� �� _^�'T♦'"'°S
�� - °�' COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �-} ��
H dd
Private Water Supply Well and Leachin Feet
g Facility(If any wells exist on
site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist within Feet
300 feet of leaching facility)
FURNISHED BY Feet
� A
F �
a
A
36
TOWN OF BARNSTABLE
II,0CATI0N q6 ' WeLchoass`4 Ave. SEWAGE.# 20 1'4 5
,YILLAGE N �,���r ASSESSOR'S MAP&PARCELoZ
INSTALLER'S NAME&PHONE NO.C�P=,,,-,ide_IeMdies 44C Mh 407-J-877
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)45 ARC56 (size) R6 K
NO.OF BEDROOMS
OWNER&.se✓I�`/� ���e� �s d/p_NeH E rA a 1rus+e 5
PERMIT DATE: �- 1�( -"2 01 COMPLIANCE DATE:
Separation Distance Between the: �V, Ad Qc,(
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 4L* 1 `' 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) 1nt Feet
FURNISHED BY t A, C�y n Jgd1 1 J CS t—L k-
--
y
I {
cz t�
� -+ w �; ►�
3u
i t
n
C
/NO. Yroe ( S Fee
THE COMMONWEALTH F MA SAC S Entered in computer:
PUBLIC HEALTH DIVISION -TOWN-OF BARNSTABLE, MASSACHUSETTS Yes
4pYILAtIOri for MIsp08Ar 6p8tP1TC CDYCBrCUtt[Ott pCrlttlt
Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. (40 W&-4V9Zj-j AqE 4qfW Owner's Name,Address,and Tel.No.
Assessor'sMap/Parcel k14AP exg IQ SV� Ok� A( r4
Installer's Name,Address,and Tel.No. 502-q77-2$7, Designer's Name,Address,and Tel.No. 570 --X73-03'7,
,040C
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size 13`A,;k$ sq.ft. Garbage Grinder( )
Other Type of Building Qt:G 111 btt A(_ No.of Persons Showers( ) Cafeteria( )
Other Fixtures ,�
Design Flow(min.required) 440 gpd Design flow provided 444 gpd
Plan Date 5— 10 da 1J, Number of sheets a Revision Date
Title 9 0 WA d HiM AXW Q E N{VAM s PM-1
Size of Septic Tank t,:5(an od Type of S.A.S.AS A120— 30146 13l®'0 1EE1)�
Description of Soil 1 aZI J UA 9&U b Go 2 4) ZS
Nature of Repairs or Alterations(Answer when applicable) I 2S `, !1..)&, an
;s ABC 14 raga S iM Fr= desi �
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance.has been issued by this Board of Health.
d Date 500.-
Application Approved by Date e
Application Disapproved by Date
for the following reasons LZ
Permit No. Date Issued
V
°} v Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN�F-&ARNSTABLE, MASSACHUSETTS Yes
application for Isp0 al-*psytem Construction
n Permit
1-
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. C�t� (�/�14k)q�-�'AyE J}y Owner's Name,Address,and Tel.No.
1 6059+V t TH
Assessor's Map/Parcel �((�(� a,g i�r( Z. g ` qu. mA
Installer's Name,Address,and Tel.No. 50S-q,77-5811 Designer's Name,Address,and Tel.No. 5'02-;. -0371
Cia►pe G11>L e1�`t PrllSt�. c.�. a e C lN��t Nq �G,
Type of Building:
Dwelling No.of Bedrooms Lot Size 13,'•{�sq.ft. Garbage Grinder( )
Other Type of Building RE IA [_ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 440 gpd Design flow provided (r 44 gpd
Plan Date rj 10 .. &01)6 Number of sheets I Revision Date
Title go wANSETr A_)(0J U E "YAW 15 PCU_r
Size of Septic Tank 1. aaF w,01) Type of S.A.S. 15� At 3"d, 610'#IFFJS�
Description of Soil 1% 1 0(AA_ 9AVA G� n" S E?:, ?LAJ
3
Nature of Repairs or Alterations(Answer when applicable) (�2S6 MC(V 1Lj6% 15CY)
�? IJ ex) n1G l0 ( , 3!6hk� H'�O � �E Ily lcrt-� IGe.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
a accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
�iged Date " (if`,p�4 �.�•Application Approved by l ,� /,,r Date
Application Disapproved by Date
for the following reasons
Permit'No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(k Upgraded( )
Abandoned( )by Nqeulmt, Gwrmaousecs L L`,
at qn WACNv5sTAy6jo Pam' has been constructed in accc'ordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ) n dated 9 h
v
Installer d4A6(4xt1,`; a476 ,Pdl�m L.e.C. Designer
#bedrooms Approved design flow (�L�(1 gpd
The.issuance of this permit shall pot be construed as a guarantee that the system ill fu�nch� sib ed. �_
Date ! Inspector
i
i
r- -
No. Fee ~
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH°DIVISION - BARNSTABLE,MASSACHUSETTS
Misposal Epstein Construction 3permit -
Permission is'hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon(; )
System located at 9. n- WA eew ik- cri—_ A vy-At U 6 Hv owiut C_Dl-_-z
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction�must be completed within three years of the date of this permit. � f Ac-)
A�Date �"'� Approved by .�' e ,
Town of 13arnstable
Regulatory Services
Thomas F. Geiler,Director
�► �, F Public Health Division
rso�ud�`� Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508.790-6304
Date: 6-3^l Z Sewage Permit# Z Assessor's Map/Parcel 2 67 S`l
Installer& Designer Certification Form
Designer: SG Erg anee.c<<n� , ThC. Installer: Cdeew"
Address: 2 95 4 e rwnvcr(% k-,�nw�y Address: QO Iy y `7(,-
Pgs1 Ware,Nnam rJA 02c*38 FClwL Lt 0263 2-
So8-Zy3•0377
On l 4J d& 64JJVt �',e, was issued a permit to install a
(date) (installer)
septic system at 90 W&CJAuseAk RucAue— based on a design drawn by
(address)
I C e n gtneer cviS , -I've. dated May 10 , 2612
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as I4.teral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than l 0' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Vocal Regulations. Plan revision or
certified as-built by designer to follow. Stripout(if required) ected and the soils
were found satisfactory. T„
JOHN
a ' CCHURCHILL
u
(IAn 's Signature iviL
4150
ner s Signature (Affix De g Here)
P ASE RETURN TO ARKS ABLE PUBLIC HE DIVISION..CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAoffice rormsWesigncrceniflcation form.doc
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W. ACRES
BgTD�� ST• PLOT PLAN OF
LAND.-TO ThE BEST OF MY KNOWLEDGE, THE FOUNDATIO �ai LOCH TED IN
SHOMM aV TNIS PLAN IS AS IT AC WALL Y EXISTp;;r; t;s _' ` OS TERVIL L E - MASS.
ON THE GROUND. �;�• -- ~�
PREPARED FOR
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DATE.' OCT. 17. .1995 i:r'hi tt
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v R.L.S. 1 DATE. OCT. 17, ISM SCALE- i -90 FT.
FLOOD ZONE A13 1 ._ E•r`' CAPE G .ISLANDS ENGFNEEAING
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{*1} Corrosion:resistant 11 gage nails and 1 6 gage staples are permitted; check IBC for addition2
Naii Unless otherwise stated; sizes given for nails:are common wire sizes. ,Box and;pneumatic n
diameter,and equal or greater length to the specified common nails maybe substituted unles
brohibited;; t
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Town of Barnstable P# 3
' Department of Regulatory Services
a,►a 91B-L , : Public Health Division Date
MAIM
rFO a�� 200 Main Street,Hyannis MA 02601
Date Scheduled La, Time Fee Pd. - ®-
Soil Suitability Assessment for Se e Disposal
Performed By: �( `4w_n(Z� �I Il C.S( Witnessed By: 7
LOCATION& GENERAL INFORMATION !(Location Address -1 &Of f A Owner's Name S V 5 6,+-%
n 1 ovh�S
1'ok� Address O Qo
Assessor's Map/Parcel: ZT-7/og1 / Engineer's Name G p, t e-> { SG &50c,;to
NEW CONSTRUCTION REPAIR Telephone# !�Z)S• 411 — 2,2 -1 56$-2 73,o.3 7 7
Land Use IRCS' 6Ni%AL- Slopes(%) 2. Surface Stones
Distances from: Open Water Body 100 ft Possible Wet Area tcO ft Drinking Water Well °O0 ft
Drainage Way 10 ft Property Line ' t c ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
Parent material(geologic) 0JTw1N5.i Depth to Bedrock > 1Zc5" 3�S
Depth to Groundwater. Standing Water in Hole: 170 ��5 Weeping from Pit Face IZp �5
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: D'41Ec-T
Depth Observed standing in obs.hole: '1u'+ C3 65 in. Depth to Soil Mottles: �tZO� , r3Cv5 In,
Depth to weeping from side of obs.hole: 7116' t1 C,5 ln. Groundwater Adjustment 11.
Index Well# Reading Date: — Index Well level ,.r Adj,factor a� Adj.Groundwater Level,o,
PERCOLATION TESL' Date zl 11 q 4 Time
Observation
Hole# , Time at 9"
Depth of Perc Time at 6"
Start Pre-soak Time @ c e'e' `p trM 4 a _�j o . 7.q - `2�2® 'lime(9"4")
End Pre-soak
Rate Min./Inch 2 mot
IV
Site Suitability Assessment: Site Passed ✓ Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back---------
***If percolation test is to be conducted within 100' of wetland,you must first notify the.
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTICVERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole# k-L
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
< ConsistenCy.%Gravel)
0-3o
DEEP OBSERVATION HOLE LOG Hole#
Depth from y Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.), (USDA) -(Munsell) Mottling (Structure,Stones,Boulders.
t i —Consisten6y.%Grave
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(iu.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Oravell
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
/ Consistency.
r.
Flood Insurance Rate Map:
Above 500 year flood boundary_No— _,Yes
Within 500 year boundary No Yes�•* T�_ � - - >-
Within 100 year flood boundary No✓ Yes
Death of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? y�5 --
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on to`z�'9 (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required training,expertise and experimice described in 310 CMR 15.017.
Signature f Date 5 2-12
ERCFORM.DOC Q:1.SEPTICIP
TOWN OF BARNSTABLE
p
LOCATION l Ga �A � l�Y u S r 1 I SEWAGE # 0 1-3 oZ 0
VILLAGE_ ,) 2 / ASSESSOR'S MAP Q LOT9 7y0 ,
INSTALLER'S NAME & PHONE NO. 0a.. h— ?-2
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)J (size)
NO. OF BEDROOMS �3 PRIVATE WELL OR PUBLIC WATER
I
BUILDER OR OWNER A---
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes 1/ �I No
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... ......OF......... a�n.,5 ���..... -------•...............
Appliratilan for Uiivniittl Workii Tonotrurtion tiprmit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at:
lQ...W.4,sh.r.1.SA... ... r. .......... AM.CskRj-..-. .We,-----�#?�..�t�c/..8.�......................
Location-Address or Lot No.
. r.tt4hk..A klar_!a�•..................•---••--.....---•-••------------•---
wder Address
a ---------------------------
Installer Address
Type of Building Size Lot_.__-..z....7.0......Sq. feet
04U Dwelling—No. of Bedrooms....1'Qvr--_--•_________________________Expansion Attic (^/o) Garbage Grinder (44
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a Other fixtures ..................................
d • ---•-•----- ----- ----- --------- -- --- -- --- --• ---------......... ............_...
W Design Flow......................... .......SS.__gallons per person per day. Total daily flow_.._....._.____..._`f .____..__._._gallons.
WSeptic Tank—Lp Visoc gacitv.!5'R07.gallons Length_ 4t= `.. Width.#.L/a...._ Diameter..._r=.... Depths�_.�.....
x Disposal Ali—No. ......�__........ Width.......t.a.'..... Total Length----- ..... Total leaching area......4 9.Q.....sq. ft.
3 Seepage Pit No.___•--_.--_-_._--- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (c, ) Dosing tank ( )
Percolation Test Results Performed by._54_--p►±f;�K..A---_1,�Us-c,_13��-E-.___---•---______ 'Date...Z-�!�� ___/__�____...
Test Pit No. 1___'h.r a.....minutes per inch Depth of Test Pit.................... Depth to ground water---/_!___y...........
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.
-
W
O Description of Soil.....0.i.Z-'y 1spsA tl..E..�ila�o� � Z Z � hYl c s�?wrn.���
?. ------------------- At :1FPF
W •••-•--•---•------....-••---••••-•••••••-•--•-••-•-•••••••••-----------••-••••-•-••--•------•---••---••••-----•------------------•••--••••...---•----------•------.•--•- •----W1MIL..--
VNature of Repairs or Alterations—Answer when applicable_.11Ps�.rks ...��sd��__- __._t'z ?l �. ts
••--------------------••--•----------------•----••-•-----------. ............................................................... +
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in acc a
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Compliant �has b issu�e�Sign .... ....................... - .... ....
7.
Application Approved By ..:. .-- `���� `r- /
..I..... .................. .............. ...- -..... .. --------_------------------- ------------....Date..-......
re
Application Disapproved for the following reasons: .............................. .. ............. .. ....... .................... . --.. ..... --....--------.
....... . . ............. ...... ..................... � ....=--....................................... . .. .................... ....................... .-- -- ............... ....... .......---............--
Permit No. ..... Issued ........... !' .. ...
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
._................OF.........Q12rn. yo.I.Ar------------.......................................
Appliratiou for Biipo,sal Works Tanstrurtion Prrmit
Application is-hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
rt........... essaraR
Location-Addr ss or Lot No.
- +jam+--. k1�sc,ae---•--•--......----•--•--------•------•-----------•--•- ��.o� .ac..� /-•�.. l �re�2tF..�c
Owner Address
W
Installer Address
Type of Building Size Lot......_4.7.F0......Sq. feet
V Dwelling—No. of Bedrooms....F"o.ur-__•_-----_-••____________.....Expansion Attic WS) Garbage Grinder (4/.)
p`J, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------------------------------•-•...--•••••------•-----•---............•••••••••-•-•••••4 .............._....----•-
g . g P P P� ` Y � y --------•-•.>� i�
W Design Flow........................SS'.__ allons per person per day. Total daily flow.___________..:.........._.. Ions.
='W Septic Tank—Liquid capacity'es ./S-aa_gallons Length -b-_.. Width..4_--/0.--__ Diameter-- Depths.-.$.-_..
x Disposal�fi—I o.......3__._...... Width_...__./.,a.-...... Total Length___.-3.a�..... Total leaching area___. f. .s�.....sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (X ) Dosing tank ( )
~' Percolation Test Results Performed by---S I-,,r _41....W.il:.s-�. _.....?.IF.................. Date---z/Z/P#.................
,aa Test Pit No. ....minutes per inch Depth of Test Pit.....13.......... Depth to ground water---/-1.............
Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a .............•-•.........•••--
o 1 _ ` ,, �
Description of Soil.....a=.L/t.......���s4,J £ �uhsatl.. ----Z--•2.---� 'h'1.crJ?t um--`�`-'-"---j...........
�.
V 7 { �Z� ; .�lJ_t.4.•_Glu-' .--f-1!-��..-.1�..._�. .l►'N.c.cQt.�,ra_.�.e.naO ...............
STEPHEN !
fs1 --....................................................................................................................... ...........................................
U Nature of Repairs or Alterations—Answer when applicable._.UFJr$r<e .__�,�skr. .__-Fa...Ys��ala ..... .....
...............................................................caw t n .........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed ...:........ . .. .. . ......--................................................--..... ........................................
Dare
Application Approved BY ...... ........ ..... ............ to L Y
Dace
Application Disapproved for the following reasons: ....................................................1;....................----......................--......---......I............
................................... ......................................................................................................................................... ....................... ........................................
�^� Dace
Permit No. ---- " ......:�7.. i Issued ............�.Date -�..�...��
Dace r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............................. .......... OF ..... -- ........��...........--..........................................................
(11Prtifirate of ..!uontyliMnve \
THIS IS TO CERTIFY, That:the Individual Sewage Disposal System constructed ( ) or Repaired
by .................................................................................................................................. ...............................................................................................
all
at . ........ �"
l� 6? 1 =, -..... - ..................... .. ................................................
has been installed in accordance with the provisions of TITLE,5 of The State Environmental Code.as described in
the application for Disposal Works Construction Permit No. H��'_'.�... ...� .GS dated ....V�t- /.... ...�.-�' i
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................T"..... +%.-.-. ,.......`. ...� ......... Inspector(:::.. --.-......��,,�. ....... ----<
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.l..... `7:. FEE........................
Disposal Workii Tonitrurtion rrrmit
Permissionis hereby granted.........................................••--'------•----•-••--••------------•----.._.....----------.._..........---.........................
to Construct or R pair ( �)-an ndividual Sewage Disposal System
atNo.......... : ='........... ......... `r .................................
Street !��.�.. .k�ated
as shownon the application for Disposal Works Construction Permit Nd. .............................•............
Board of Health
DATE................................................................................
f Form 1255 H HOBBS&WARREN IU Publishers
JQ
TOWN OF BARNSTABLE
o UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS
NAME
ADDRESS �� 1�n��c N uS t; Aye - VILLAGE 146116
LOCATION OF TANKS: CAPACITY: TYPE OF FUEL. AGE: TYPE:
OR CHEMICAL
s7 alOOl) GAL. 011-
(Give same information for any additional tanks on reverse side of card)
DATE OF PURCHASE OF EACH: 1. 1 2. 3. 4.
DATE OF FIRE DEPARTMENT PERMIT: U rJ o 9- A 130VT M AP.e-++ 197�
TESTING CERTIFICATION SUBMITTED: ,�tr��ssur-e �s 124 XL11L
PASSED DID NOT PASS
---------_--------------------
T.O.F. EL.= 15.4'+- EXISTING EXTENSION RISER OVER INISH GRADE OVER D-BOX= 12.1'-+ 4"SCHEDULE 40 PVC MIN. SLOPE 1 % FINISHED GRADE OVER BIODIFFUISERS= 11 .6' - 12.5' GENERAL NOTE S
SLOPE @ 2%MIN.
INLET&OUTLET TO BE SECURED INSPECTION PORT WITH
TO UNAUTHORIZED ACCESS REMOVABLE WATER-TIGHT COVER OVER ACCESS BOX TO WITHIN 3"OF I- UNLESS OTHERWISE NOTED,ALL SYSTEM COMPONENTS AND CONSTRUCTION
FINISH GRADE 1+ RISER TO WITHIN 6"OF FINISHED GRADE F.G. (ONE PER OUTER ROW) METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL
@ FND. EL.= 14.0 - F.G. OVER TANK EL. = 12.5'± 5-DIA. OLITLET(S) CODE AND ANY APPLICABLE LOCAL RULES.
2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER.
PROPOSED 4" 9" MIN. IN. 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL
EXISTING 4" PVC SEWER PIPE 36"MAX. 36"MAX. TOP OF SAS B.O. 9.53'
SEWER PIPE I SYSTEM UNLESS OTHERWISE NOTED.
3"DROP MAX F PROVIDE WATERTIGHT 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
6' 3' L 8'±3" 9"
IF�IF7
2- DROP MIN MIN.SLOPE @ 1% JOINTS (TYP.) ELEVATION =9.53' FOR A DISTANCE OF I 5'AROLIND THE PERIMETER OF THE SAS. UNLESS A
4"PVC IN FROM 1.33' 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF
10" Ir i 16"
E4 (TYP.) THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
O4" SEPTIC TANK 4" PVC OUT TO 0.901 .75-(TYP
*10.0'±� LEACHING FACILITY tdt=j 11
W-1 j 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM.
n10.7 (TYP)
6.
12" 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
CONTRACTOR CONTRACTOR SHALL OUTLET TEE 9.57' MIN.
9.101 8.20' (laid flat) -2.876(34.5-)_�
SHALL VERIFY SIZE 48' VERIFY CONDITION OF - MIN. 9.40' 5.0' (TYP.) 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK
AND CONDITION OF EXISTING TEES GAS BAFFLE 6"CRUSHED STONE (TYP.) 5'MIN. 14.375' FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS
EXISTING SEPTIC AND REPLACE AS r8u�OVER MECHANICALLY REQ'D NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
TANK NECESSARY COMPACTED BASE 25.0' AND DESIGN ENGINEER.
5 OUTLET DISTRIBUTION BOX (TYP.) 8. ELEVATIONS BASED ON N.G.V.D. 1929 DATUM OF 11.58' ESTABLISHED ON A
TO BE INSTALLED ON A LEVEL STABLE GROUND WATER ELEV.= < 2.00' BIODIFFUSERS (END VIEW) NAIL SET IN UTILITY POLE#17/1 AS SHOWN ON PLAN.
BASE. FIRST TWO FEET OF OUT.LET 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
EXISTING 1 ,500 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. BIODIFFUSERS (PROFILE) THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT
CROSS SECTION VIEW (BY INFILTRATOR SYSTEMS, INC.) 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES
TO THE DESIGN ENGINEER.
*CONTRACTOR TO VLRIFY EXISTING ELEVATION PRIOR SEPTIC TANK PROFILE DISTRIBUTION BOX DETAIL ARC 36HC (#3616BD) BIODIFFUSERS (H-20)
TO ANY WORK & NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT.
------- 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING
TEST PIT DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM
PERC NO. 13618 APPROPRIATE AUTHORITY.
ZONE 2 INSPECTOR: Donald Desmarais, R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS
EVALUATOR: Michael Pimentel, E.I.T. LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE
THEY SHALL WITHSTAND H-20 LOADING.
C.S.E.APPROVAL DATE: Oct. 1999 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES.
DATE: April 25, 2012
APPROXIMATE FLOOD ZONE LINE DIGITIZED PER TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE
FEMA MAP#250001 0006 D (DATED JULY 2, 1992) a MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY.
ELEV TOP 12.00'
MAP 287 REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY,
r%3 ELEV WATER <2.00' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3).
PARCEL85 PROPOSED TOTAL 25 ARC 36HC (#3616BD) H-20
BIODIFFUSERS IN A FIELD CONFIGURATION PERC RATE 2 min./inch" 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
60
EXISTING 3 FLOW DIFFUSERS SURROUNDED DEPTH OF PERC = 16. PROPOSED PROJECT IS LOCATED WITHIN:
BY CRUSHED STONE (10'x 30' FOOTPRINT);
CO
LOCATION PER AS-BUILT CARD PROPOSED INSPECTION PORT WITH TEXTURAL CLASS: 1 ASSESSOR'S MAP 287 PARCEL 84
0 ACCESS BOX TO GRADE (TYP OF 2) 'Perc rate based on 1994 permit(No 94-320) OWNER OF RECORD: SUSAN A.H. &DUDLEY E. THOMAS, JR., TRUSTEES
11_ N84020-o.5-W
1:6 THE THOMAS HYANNISPORT REALTY TRUST
"IT 164-03' HEDGE ROW HYAN on 12.00' P.O. BOX 426
rid ADDRESS:
CB(FND)
LOCHYANNISPORT, MA 02647
USk"
Z:x_1_7 Fill X . ..... ...
` C�XX1r
FEMA FLOOD ZONE B&C
COMMUNITY PANEL# 250001 0006 D
30" 9.50'
z 17. DEED REFERENCE: DEED BOOK 16146, PAGE 65
LU
SHRUBS
18. PLAN REFERENCES: 1.) P.B.43, PG. 87
< 2.) P.B. 26, PG. 95
of
BH 00
HCA
-GARDEN 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION.
+
GARAGE • Ughi Medium Sand
20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY
MAP 287 G) 'N" C 40 2.5Y 6/6 FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY
PARCEL83 S FOR USES OF THIS PLAN OTHER THAN ITQ INTENDED PURPOSE.
,;olr 4( 21. IN ACCORDANCE WITH 310 CMR 15.401 -15.405, THE FOLLOWING LOCAL UPGRADE
A,
ro 0 APPROVAL IS REQUESTED FROM 310 CMR 15.211 (1):
#90 LOCUS PLAN -4111- (1.) A 3.0'WAIVER(20.0'- 17.0') FOR THE SETBACK FROM THE PROPOSED LEACHING
EXISTING (4 SYSTEM TO THE FOUNDATION WALL.
4-BEDROOM SCALE: 1" 1000'
_j T-P 120", 1 2.00'
DWELLING 101 No Mottling, Standing or Weeping Observed
o0)
Cn
TOF = 15.4'±
0 3)
DESIGN DATA
TEST PIT DATA LEGEND
PROP.40 MIL. IMPERVIOUS G PERC NO. 13618
50xO EXISTING SPOT GRADE
GEOMEMBRANE LINER; A� Donald Desmarais, R.S.
TOP EL.=9.53'; BOT. EL.=5.53' INSPECTOR
MAP 287 _'Z� EVALUATOR: Michael Pimentel, E.I.T. 50 - - - EXISTING CONTOUR
2x O 0 NUMBER OF BEDROOMS (DESIGN) 4 -r5O PROPOSED SPOT GRADE
PARCEL84 < C.S.E.APPROVAL DATE: Oct. 1999
0 -4c, DESIGN FLOW 110 __QAUDAY/BEDROOM
13,428 S.F.± 0 DATE: April 25, 2012 PROPOSED CONTOUR
7.01 TP oo TOTAL DESIGN FLOW 440 GAUDAY
TEST PIT#: 2
E/T/C EXISTING UNDERGROUND UTILITIES
54 2x DESIGN FLOW X 200 % 880 GAUDAY ELEV TOP 12.00'
USE EXISTING 1,500 GALLON SEPTIC TANK ELEV WATER <2.00
PERC RATE ' _w_w_ EXISTING WATER LINE
LSA HC-
GAS EXISTING GAS LINE
L7 x
0 0 (2 .0, 1 Ox4' INSTALL 25 - ARC 36HC (#3616BD) BIODIFFUSERS (H-20)
X1 DEPTH OF PERC
.0
TEST PIT LOCATION
x Al- TEXTURAL CLASS: I
< I Z - -
0 x PROP. D-BOX SYSTEM CAPACITY EXISTING 1,500 GALLON SEPTIC TANK
;r (TOTAL L.F. OF BIO'S&COUPLINGS)(4.8 SF/LF)(0.74 GPD/SQ.FT.)=GPD
c, ' i
EXISTING 1,500 GALLON (125.0')(4.8SF/LF)(0.74GAUSQ.FT.)= 444.0 GAL. LEACHING/DAY 0.10 SEPTIC TANK TO BE 12.00' PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE
x UTILIZED IN THIS DESIGN 1 Ox5'
0
0 PROPOSED DISTRIBUTION BOX
w X1 TOTALS:
ItI
LEC. METER IC-1 z x TOTAL NUMBER OF BIODIFFUSERS: 25 Fill
PROPOSED ARC 36HC(#3616BD)BIODIFFUSER(H-20)
J U_ x TOTAL NUMBER OF COUPLINGS: 0
U,
4__ TOTAL LEACHING AREA: 600.0 30" 9.50'
CB(FND) i / X .
'\rO ; I TOTAL LEACHING CAPACITY: 444.0
x OxT I
SWING-TIES REV. DATE BY DESCRIPTION
884020105"E HCA HC-2
7-5 -fj'� DESCRIPTION NOTE:. PROPOSED SEPTIC SYSTEM UPGRADE
Benchmark BIODIFFUSER CORNER(1) 39.2 17.8' EFFECTIVE LEACHING AREA OF 4.80 SF/LF OBTAINED FROM THE PREPARED FOR:
C) Nail in U.P.#17/1 DEPARTMENT OF ENVIRONMENTAL PROTECTION APPROVAL LETTER
Elev.=l 1.58' BIODIFFUSER CORNER(2) 51.6' 29.7' "MODIFIED APPROVAL FOR GENERAL USE" ISSUED TO INFILTRATOR C Medium Sand CAPEWIDE ENTERPRISES
N.G.V.D. 1929 SYSTEMS, INC., DATE OF ISSUANCE OCTOBER 3, 2003 (LAST MODIFIED 2.5Y 6/6
it
BIODIFFUSER CORNER(3) 46.3' 46.2' 1 MARCH 14, 2012). TRANSMITTAL NUMBER=X235253.
LOCATED AT
BIODIFFUSER CORNER(4) 32.0' 39.7'
90 WACHUSETT AVENUE
WACHUSETTAVENUE
(45'WIDE LAyOUT)
HYANNISPORT MA 02647
,
SCALE: 1 INCH = 10 FT. DATE: MAY 10, 2012
120" 2.00'
0 5 10 20 40 FEET
NOTES: l No Mottling, Standing or Weeping Observed f
J0 L. PREPARED BY:
1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF j RESERVED FOR BOARD OF HEALTH USE CHUB MILLR.
JC ENGINEERING, INC.
EACH SEPTIC SYSTEM COMPONENT. cI IL )
f 10 2854 CRANBERRY HIGHWAY
2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF EAST WAREHAM, MA 02538
SITE PLAN THE PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST
PIT DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL ► 508.273.0377
BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. Drawn By: BSMI/MCP Designed By:MCP 1 Checked By:JLC JOB No.2185
SCALE: 1"= 10'
i
|
�
OCEAN ST
10 FT. MINIMUM z
4" SCHEDULE 40 PVC
TOP OF FOUNDATIO PITCH 1/4- PER FT. LOCUS
ELEVATION CONCRETE COVERS
SETT AV 0 HYANNIS
MIN PITCH 1/8" PER FT.
CONCRETE COVER
FLOW LINE
2 Pr_ NANTUCKET SOUND
ELEV. ELEV. 1110" MIN. SEE TABLE
LEVEL
GTON
LOCUS
cMUSEr
LE
TAB
ELEV. WA&he- 54w r%4- LOCATION MAP
DISTRIBUTION BOX ASSESSORS MAP PARCEL
GALLON MORE THAN ONE OUTLET -2 60vr- C�djj ft cp SY'C'J nd WZA+r- 3.4 ZONE------
MIN. FRONT SETBACK --- FEET
SEPTIC TANK MIN. SIDE SETBACK ----- FEET
LIQUID DEPTH IN SEPTIC TANK DEPTH OF OUTLET TEE BELOW FLOW LINE cl�o�na we-hc leesc.41,7,p 7,ikclho�;( 40"eoo CI<14,17 -V&17 41 9" f r-10 Ll C -_------ MIN. REAR SETBACK ————— FEET
5 FEET 19 INCHES 'I). �1,icj CX, fru,wiet oedl polhe ffphc DESIGN CALCULATIONS
6 FEET 24 INCHES
conjowco- NUMBER OF BEDROOMS
4)Cc J�s /A40 GARBAGE DISPOSAL UNIT
SEWAGE DISPOSAL SYSTEM PROFILE h1Pm TOTAL ESTIMATED FLOW
y.
NOT TO SCALE GAL./BR./DAY X BR.) 44�2 GAL./DAY
!
EXISTING WOOD FRAME BLDG LEACHING AREA REQUIREMENTS
AV 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. i
TITLE 5 AND THE TOWN OF RULES AND
N\F GERALD DOHERTY REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 13 OT-r6wi Q
N LOT 85 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WATER LEVEL ADJUSTMENT
\F ROSARIO CELENTANO WITHIN 12' OF FINISHED GRADE. MASONERY UNITS USED TO BRING
COVERS TO GRADE SHALL BE MORTARED IN PLACE. TEST DATE WATER LEVEL— 2, f
' REQUIRED SEPTIC TANK CAPACITY _w_w_.'_GAL./DAY
ACTUAL SIZE OF SEPTIC TANK 7,1'1_GAL./DAY
i
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'
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