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HomeMy WebLinkAbout0037 WALTON AVENUE - Health (2) 37 Walton Ave Hyannis 4 TOWN OF BARNSTABL.E LCATION 37 GU!¢lT©� ►//= SEWAGE # 2005— 2g7 VFLLAGE R"44, ,414 ASSESSOR'S MAP & LOT.3/0— 0/�' 1t. 7-- INSTALLER'S NAME&PHONE NO. .SOg—y20- 971 1/0.5C'4i ,i c �i4rro3 SEPTIC TANK CAPACITY L5^000 LEACHING FACILITY: (type) .SOD (size) x ZS NO. OF BEDROOMS 3p BUILDER OR OWNER PERMIT DATE: '2 2-OS� COMPLIANCE DATE: /0-7 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 faci 'ty) Feet Fumished by ..— 1 J S e � a I � h 1� i 1::� `7r "r TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT5/0 — ov' .tea INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) t NO. OF BEDROOMS- PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER del, DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: / VARIANCE GRANTED: Yes GJwo #aa1 e -� �� �, ...5 �.- . .-, �'-� ,, Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: qYes / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Migoml *potem Construction Permit Application for a Permit to Construct(/Repair(4-- 0pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. .3;7 6f/W roh 14✓F Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Q$-y2O- 9737 Designer' Name,A ress and Tel.No. S'D -$�,j—Q� 7"7 j�ZvY Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)�1 h ?1� /fDD �1� -�,d7iC 00 �� — 'S' ti /7�u f/ 12F,4i 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 Certifi- cate of Compliance has been issued by this Board of Health. Signed 0 Date Application Approved by A Date Application Disapproved forte following reasons Permit No. Date Issued t?'� 'r..r.*""5...Y�-ri.ri -[+.yril••.,.�.p�'kn'.Y+✓'�'.-ro.«-..•�r�4� .:;T.�; Y��x.n� • rr..�'"'7.v`,,.,e.. i'-^/S.,J '^.`wP•--�""y'�"+rM"^;ri.�r ..r,..rira'vtlrrc'.r+a�'g�,.:'M't,�x t No. '` Fee!laqYes� -THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS annficat on-for Migool *pgtem Construction Permit AApplication for a Permit to Construct(Repair( Upgrade( )Abandon(" ) {El Complete System El Individual Components 2; Location Address or Lot No. 37 ww rTl V— Ow er's Name,Address and Tel.No. % Ny�ni�%s t GA�h�r� 5 rc vi:�5 Assessor's Map/Parcel Installer's Name Addre s,and Tel.No.S D�"t/�p: 9��$ D sign Qddd ens and Tel.No. S - 3� �� l� UA✓r Jd Type of Buildings Dwelling No.of Bedrooms -3 Lot Size sq.ft. Garbage Grinder( ) &ier Type of Building No:of Persons Showers( ) Cafeteria( ) Other Fixtures 7;- Design Flow. gallons per day. Calculated daily flow gallons. Plan Date Number:of sheets Revision>Date, t Title Size of Septic Tank Type of S.A.S. Description of Soil. Nature of Repairs o)r Alteratio}s(Answer when a plicable) Z�S'�// L%f9cGii�a�j 4r",71 , s i 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 Certifi- cate of Compliance has been'ssued by th's Boar of�alth. I ,Sigti Application Approved by _ v Date VI M MOZ9 Application Disapproved for the following reasons . Permit No. � f — a Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the�0 site Sewage Disposal System Constructed(e—+Repaired pgraded Abandoned( )by J525 at 37 alwlyde �0d constructed in accordance with the provisions of Tittllg 5 an the for Disposal System Construction Permit No dated ; Installer Lost`, v-� r � Designer The issuance of this permit shall -ot be construe as uarant.e that the system will 61 ' n as es'" ned. Date I n 1�3 Inspector _ �'"~--- No. TOPUBLIC FeeTHE COMMONWEALTH OF MASSACHUSETTS HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi$p0$al *pgtem Con$truction Permit Permission is hereby granted to Construct(G-j'Repair �"Upg_�_A de( )Abandon( ) System located at 3 w"'�� � Al =_ y/�brrris and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction Iust be com eted within three years of the date of this pe nft Date:_ K 111 Approved by Town of Barnstable °FINE r Regulatory Services Thomas F. Geiler,Director BARNSTA MASS. ' Public Health Division 16,39.°ren Mai a Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-8624644 Fax: 50 790-6304 Date: Sewage Permit# 'Zliy7 Assessor's Map/Parcel'3- 10 41) Installer & Designer Certification Form Designer: , Installer: Address: . 6jt \�,�,� Address: �-�"� ®j IA S On (l ZZ al9 was issued a permit to install a V(date)' (ins aller) septic system at based on a design drawn by (address) 1 dated c3 ZV Zr�S < (d signer) Certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such m lateral relocation of the distribution box and/or se tic tank. Stripout (if required) was inspected and the soils were found satisfacto �' 6k*�� I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or'any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required) was inspected and the soils were found satisfactory. , (Installers Signature) -�DesiNia s Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice formMesignercer ification form.doc Commonwealth of Massachusetts Title 5 Official Inspection Form _ < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M rM Property Address F OK� Owner Owner's Name -4 information is required for every G 4P1 if e c� page. Cityfrown State ZipCode Date o Inspec on Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, C.�54 use only the tab 1. Inspector: key to move your cursor-do not use the returnW a✓n� p h / key. Name of Inspector 10 - Company Name Company Address '— ---- --- __ Clty/Town Sa 1 �0 ��nO State D Zip Code Telephon Number C7� 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 an, a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CM 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs further Evaluation by the Local Approving Authority Inspector' Signature Date The sy tem 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 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.doc•rev.6116 Title 5 Miicial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is n� A required for every 4415 /j/�C,► page. City/Town State Zip Code Date of In pectio B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System sses: 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of.Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally Unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System /Form -Not for Voluntary Assessments Property Address Owner �^ '^Je Owner's Name information is �f l required for every19 page. City/Town State Zip Code Date of I spec on 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): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is 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.doc•rev.6/16 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 Property Address CGS Owner Owner's Name All information is required for every C+✓4 ir S Q 6 O page. Citylrown State Zip Code Date of I pecti B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or /clogged SAS or cesspool ❑ L^J/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 �la/4,1 14Ire Property Address Owner �jG� ��✓ Owner s Name information is ' required for every Ot v)r/J/ Da G O / r, / page. City/ own State ZipCode Date of Ins ectio 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: E] An 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 tributary to a surface water supply. or ElAny portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ice' And portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Ly' A ny 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.] ❑ ❑/ I a system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Systtem� Form -Not for Voluntary Assessments Owner Property Address Owner's Name information is required for every q�t✓I/l TState�' �a60/ page. City/Town Zip Code Date of I pecti C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes ❑ mping information was provided by the owner, occupant, or Board of Health ❑ e any of the system components pumped out in the previous two weeks? ❑ he 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? 19 LJ 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? LJ 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: L'_f LJ 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: 2 2 Number of bedrooms (design): Number of be drooms edrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 1330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address 4001G Owner G' n ' ? information is POwner's Name //�� Q / required for every Q,il✓/� page. City/Town State Zip Code Date of Ins ectio D. System Information Description: / Sao xe, // _ / J)1_5 441 Z,-A all .2 Number of current residents: Q Does residence have a garbage grinder? ❑ Yes PJo Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes r-.No �o Seasonal use? ❑ Yes Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ j No Last date of occupancy: D Commercia!/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Property Address l4o0t A vs-' Owner Owner's Name r information is required for every q A Qd-G 0/ page. City/Town State Zip Code Date of spe on/ D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: V ze a� — D U'H-✓ 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 Sy m: 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.doc•rev.6/16 Title 5 Official Inspection Form: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 Property Address Owner information is Owners Name ✓JGG� required for every N l J (� xv:: / � page. City/Town State Zip Code Date D. System Information (cont.) Approximate age all components, date installed (if known)and/sourc f information: 00J !30/��( y-- � COS Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: // feet Material of constructi;;'40 El cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: AD feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below gr de: feet Mated of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: . 12 years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) Yes ❑ No Dimensions: C) Sludge depth: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner information is Owner's Name required for every page. City/Town State Zip Code Date of) spect on D. System nformation (cont.) Septic Tank(cont.) 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.): 9,qA,79 l G ri �✓ -av�cl �ee.s �✓1 (,oh c'1?1oh //0 Z-'OR4,f Grease Trap (locate on site plan): Depth below grade: feet Material of construction: r ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 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 Property Address Owner information is Owner's Name c9"O/required for every ✓1 f /jpage. Cityrrown State Zip Code Date of I;M� Pi D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 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 Property Address Ile, ./ Owner information is GR� en ` Owner's Name ` required for every GiD h 4 page. Cityfrown State Zip Code Date of I pecti n D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 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 Property Address Gl 2v► �/ Owner Owner s Name information is / required for every ✓I t�l f D� G©/ / /7 page. City/Town State Zip Code Date of Ins ectio D. System I ormation (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: --- -- ❑ overflow cesspool number: ❑ innovative/alternative system Typeiname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): oh lAle ��t /vl-e SI s O� /ciH li C c.c [ JAI-e 071 Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ZI Owner OwneR �! � r's Name information is required for every Cj/)ki i page. City/Town State Zip Code Date of Inslec�Zon D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 0 / � Property Address Owner Owner's Name information is � 0 oC l 6 0/ / '7 / required for every ✓)!�I /,/ page. Cityffown State Zip Code Date of speot on D. System Information (cont.) Sketch Of Sewa posal System: Provide a view of the sewage disposal system, including ties to at least two anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where is water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately 9,4c ►v- i . - �5,00 y— 14 a 3 - 3 t5ins.doc-rev.6116 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 y< Property Address Owner Owners Name information is required for every o)P14/J page. City/Town State Zip Code Date of Ins ction D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: -- /C) — feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ served site(abutting property/observation hole within 150 feet of SAS) Checked with loc I Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must de ribe.how ZI established the high ground water elevation: / / L aH .e /0 G wi-4, 7`v I /' L't H v �d Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r` �XI/'7 �g NO V7 Owner Property Address Owners Name information is / / required for every page. CityTrown State Zip Code Date of In ectio ry E. Report ompleteness Checklist Inspection Summary:A, B, C, D, or E checked Ud/lInspection Summary D(System Failure Criteria Applicable to All Systems)completed V em Information—Estima ted depth to high groundwater ketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 TBIe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is required for every Hyannis Ma. 02601 7/12/2014 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important When A. General Information �t�l filling out forms I . on the computer, ° use only the tab 1. Inspector: . key to move your �� Q cursor-do not R ' aymond Dumas use the return Name of Inspector key. Dumas Landscape Const. "ICI Company Name �4 564 Old Stage Rd. ' Company Address Centerville Ma. 02632 City/town State t 508478-0249 S1437 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 16.000).The system: .® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority r \�►C2aad 7/12/2014 `• Inspector's gignature 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. A I 3 1(q t5ins•3113 Title 5 Official InspectVFo .,O.Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is Hyannis Ma. 02601 7/12/2014 required for every y page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. } The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. . *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y. ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 official trapection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is required for every Hyannis Ma. 02601 7/12/2014 page. City/Town 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 sewage4backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is 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 cersbcif,nt iv,�A 12.-1i.!!1W -, 1�0 w 3 MLqGLll,� (20"7[841 CLV C-il U-Ma OL bf lt.A -WAN TPsf 103 -nOIVW V� "of tnuctiou.,vil lu f: WuuucL bLoisc;Lin;I Ic p4wr bill fwjce. Fpotzaq of scalip ;A,,�tj�40 lc ljj c bLojec, )"—Xiot4 um xoc,,, u-ldaitzs taqpsz ef"z1frLn"Ou Ph pir; 2mq ol 1-jesIrp p QLqst P)Cic,;GLo-'j, it I 1 U 140(Exb',Ziu PCP%A'/ px,(so no E—I A C-I V C3,, 14D(Ex -1 i-1211 PDX' ip toA 01,00, OL La C1C r D U,L I?kCVjlAtq 3b(I-xbjqllj P�;.OIA.,: PLO JeA, Ow-cf dP)94LO LOb!SK;ctj A 1:3 V,L) _Xt P;0 P:,-W).'A) f;J ptok (S. ou C�t OPPJ�mpq 0,07; j OL an ,a v PLOrGU Ot nl)13rk-�ajd q,';IPJ r, j p p ms Lctisi.L,�fl �-.nujb r;psujp�t wh�Asi,-Jwva wof cbstqflotj ly 8�?JGW,14111 bz�aa fv4j; Roslq 01 140Z-1,11-t Fbb",crolk i. !Oij (c)rtouO U, it. VIP vt,cogs...`....._ oqs Dw,.rtxa",lct.')U U'!a OSG j�tzr,wsde 0!40c0sl 2AVOW 60W-,V�04 tOL AOln;jPa-,�fnri�>LvGvja C r T 4 c 4 to a n�el- C), V) t Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Walton Ave. lug Property Address Barbara A. Stevens Owner Owner's Name information is required for every Hyannis Ma. 02601 7/12/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 Y day flow t5ins•3/13 Title 5 Official Inspection Forth: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 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is required for every Hyannis Ma. 02601 7/12/2014 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ . the system is within 400 feet of a surface drinking water supply ❑. ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone it 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 Idle 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 M 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is required for every Hyannis Ma. 02601 7/12/2014 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following:- Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week,period? - , ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® 0 Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: - ® ❑ Existing information. For example, a plan at the Board of Health. El ® Determined in the field.(if any of the failure criteria related to Part C is at issue approximation,of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17. f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Walton Ave. Property Address , Barbara A. Stevens Owner Owner's Name information is required for every Hyannis Ma. 02601 7/12/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1500 gallon septic tank, D-box, and 2 500 gallon leach chambers as per plan on record at Barnstable B.O.H.. Number of current residents: 1 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 Seasonal use? ® Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: ` 2013 30067 gallons, 2012, 22,500 gallons; 2014, 24,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: occupied now; Date Commercial/Industrial flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title'5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Walton Ave. 4 Property Address Barbara A. Stevens Owner Owner's Name information is required for every Hyannis Ma. 02601 7/12/2014 page. City/Town State Zip Code Date of Inspection ion 1 D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): Occupied now General Information _ Pumping Records: Source of information: 2010 Sewage treatment plant DeBarros Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? By Pumper Mass Cape Reason for pumping: Maintanance 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•3/13 Title 5 Official Inspection Form: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 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is required for every Hyannis Ma. 02601 7/12/2014 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: 2006 upgrade Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 42 inches below top of foundation feet Material of construction: ® cast iron ®40 PVC ❑.other(explain): Distance from private water supply well or suction line: approx 20 ft away from where town water comes in at front right of Comments (on condition of joints, venting, evidence of leakage, etc.): all good Septic Tank(locate on site plan)' Depth below grade: 12 inches below grade feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain). If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: none F 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 M " 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is Hyannis Ma. 02601 7/12/2014 required for every y ' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle none Scum thickness none Distance from top of scum to top of outlet tee or baffle none Distance from bottom of scum to bottom of outlet tee or baffle none How were dimensions determined? dip stick ruler Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped 1500 gallons A �• Grease Trap(locate on site plan)` Depth below grade: feet 1 Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 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 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is Hyannis Ma. 02601 7/12/2014 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees good no evidence of leakage Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: All tees good Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): 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 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is required for every Hyannis Ma: 02601 7/12/2014 page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 liquid at level with no carryover I Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* " Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 2-500 gallon chambers with 4 ft of stone around as per plan t5ins•3/13 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is required for every Hyannis Ma. 02601 7/12/2014 page. City/Town State, Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching,galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 2-500 gallon precast Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Very good condition checked with camera f Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 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 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is required for every Hyannis Ma. 02601 7/12/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): j 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 M 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is Hyannis Ma. 02601 7/12/2014 required for every y page. Citylrown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i Commonwealth of Massachusetts Title 5 official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is required for every Hyannis Ma. 02601 7/12/2014 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: 12+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date 005 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Plan on file no water at 12 ft 5 ft plus of separation ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Board of Health Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 37 Walton Ave. Property Address Barbara A. Stevens Owner Owner's Name information is required for every Hyannis Ma. 02601 7/12/2014 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 O • TOWN OF BARNSTABLE• LOCATION SEWAGE # 2005- 287 VILLAGE_. s ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. `/20- 973 S J osG/"� �� ��is►sas SEPTIC TANK CAPACITY /.5'000 LEACHING FACILITY: (type) S-00 (size) /.f X ZS� NO.OF BEDROOMS .3 BUILDER OR OWNER 101111rAq- PERMIT DATE: �O - 2-OS r 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 faci •ty) Feet Furnished by 255���� .� cvr�/tom f�✓F • i ` 37 t • i ' 1• yi i t 1 ASSES SORS MAP: 3I -TEST HOLE LOGS LP �G PARCEL D X/lf"1-" FL00 ZO A G SOIL EVALU TOR. L NOTES NE y WITNESS:, REFERENCE: L�J� � DATE: ?DOG I L PERCOLATION RATE:, L 1 , 1) The installation shall comply with Title.V and Town of Barnstable Board of 1tV L .. - Health Regulations. q3 = a, ,� � � t,x � 2) The installer shall verify the location of utilities, sewer inverts and septic TH- I TH-2 components prior to installation. Lv p 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. r: 4) This plan is not to be utilized for property line determination nor any other t b ` purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. LOCAT I ON MAP ITS _ / 6) Parking shall not be constructed over H1O septic components. �! �} 7) The property is bounded by property comers and property lines as depicted. /► 8) The property owner shall review design considerations to approve of total Aj'fb design flow to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the design flow. 9) The existing cesspools shall be pumped and filled with material per Title V abandonment procedures. ! ) IF 10)System components to be 10 feet from water line. 0 tt� 12• `(13ik l ?=. 1 i) If a garbage grinder exists it is to be removed. �� M s � � SEPTIC 5YSTE DE N ',.,FLOW- EST I MATE ,BEDROOMS AT GAUDAY/BEDROOM • GAL/DAY k SEPTIC TANK } / !SL.SALlDAY x 2 DAYS _ GAL y l USE-M)GALLON SEPTIC K - 04 � ,�1 / 0 0 O " S01L ABSORPTION SYSTEM -� y Z ._� k AREA: BOTTOM AREA: r SEPT I � SYSTEM SECT I ON T5� o� mWo Aj Y 1 >M� rat � ' LT Z t G N X � ' ! ' 701 e 0o GAL 32 SEPTIC TANK �d2 � , (Q -_ 1 T - --- TbW 1� t . —�H Uft �. S ti `n � 14rL; -_ - SITE AND SEWAGE PLAN [ ` '— L-OCAT I ON : O 00 N Mw"6 . PREPARED FOR : i (� P O - �'t' SCALE: DAV 1 D B . MASON 9,� DATE: DBC ENV I RONMEiitAL DESIGNS z EAST SANDWICH . MAj DATE HEALTH AGENT f � _ ( 508� 833-2i77 I - I I E