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HomeMy WebLinkAbout0043 WALTON AVENUE - Health 43 WALT(!-M- Hyannis A = 310 — 015 i 3/D- 01r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments *T 43 Walton Ave '; V Property Address Paula Deitke Owner Owner's Name/ information is required for every Hyannis V MA 02601 10-29-2019 page. City(rown 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 �/ �•�,, on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road � Company Address Teaticket Ma. 02536 City/Town State Zip Code fen 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10-29-2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is required for every Hyannis MA 02601 10-29-2019 page. Cityrrown 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: ® 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: This 3 bedroom home has a H-10 1500 gallon septic tank and a D-Box feeding two leaching chambers with stone. At the time of the inspection the leaching was dry and there were no visible failure criteria found. 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 u 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is required for every H y annis MA 02601 10-29-2019 - page. Citylrown 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is required for every Hyannis MA 02601 10-29-2019 page. Cityrrown 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 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is Hyannis MA 02601 10-29-2019 required for every y page. Citylrown 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 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 El El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is required for every Hyannis MA 02601 10-29-2019 page. Cityfrown 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? ® El 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is required for every Hyannis MA 02601 10-29-2019 page. CitylTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: =n do19 c�.:,oAer i..3aS Shin o 01 '2)^ C05O0 CLrbLic4r4- mos us-cA ov,,A '►r� D()l-1 r It + IDO Cvb',c 4pec4 C.�aS �f5rd Sump pump? ❑ Yes ® No Last date of occupancy: Aug 2019 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is required for every Hyannis MA 02601 10-29-2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was 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 `I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is required for every Hyannis MA 02601 10-29-2019 page. Citylrown 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: 06-20-2014 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 48"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is required for every Hyannis MA 02601 10-29-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 36"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: H-10 1500 gallon • Sludge depth: 2„ Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1" 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 13" Sludge judge 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.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Walton Ave V� Property Address Paula Deitke Owner Owner's Name information is Hyannis MA 02601 10-29-2019 required for every page. Cityrrown 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form `I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` . 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is required for every Hyannis MA 02601 10-29-2019 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 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. 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 Ala Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is required for every Hyannis MA 02601 10-29-2019 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: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form _ F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is required for every Hyannis MA 02601 10-29-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection the leaching was dry and there were no visible failure criteria was found. 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.): 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 43 Walton Ave V Property Address Paula Deitke Owner Owner's Name information is Hyannis MA 02601 10-29-2019 required for every -y page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is Hyannis MA 02601 10-29-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 TOWN OF BARNSTABLE LOCATION AM 1A)%,JJoJ ktLe SEWAGE# 7i K �LC3Lf VILLAGE Y ASSESSOR'S MAP&PARCEL .1 IV t 5' INSTALLER'S NAME&PHONE NO. n�rR--qw-q 3 SEPTIC TANK CAPACITY j�:o LEACHING FACILITY:(type);.-ScM:, �.b (size) late NO.OF BEDROOMS .. OWNER 0►e r V PERMIT DATE: % Q !'r COMPLIANCE DATE: Separation Distance Between the: 1it�v r c.t P erc Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 1A y '33 D - Lj o D - y x �Tt 1 157 1 —5-0 N 7 (N (VT FVV-ti 3A x L Lil i Commonwealth of Massachusetts Title 5 Official Inspection Form �- III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. !% 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is required for every Hyannis MA 02601 10-29-2019 page. Corrown 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: 11 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water,elevation: I augered a hole to 11 feet to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts �^ Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Walton Ave Property Address Paula Deitke Owner Owner's Name information is required for every Hyannis MA 02601 10-29-2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 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 _ �o-�-Inc,.,•, off' S..Q ,S � 1 g` No Mao 15insp.doc•rev.1/26/2111 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOWN OF BARNSTABLE LOCATION SEWAGE#L[7I q - 209 VILLAGE hlye,ay�9.�S ASSESSOR'S MAP.&PARCEL 1WrL �� p I INSTALLER'S NAME&PHONE NO. cy ` c,�A�ccm&wTme Sag Y20 41�s3� SEPTIC TANK CAPACITY LEACHING FACILITY:(type}-Se?2 ar. c 6oA r rS (size) !�• K S X 2 NO.OF BEDROOMS '7, OWNER ►P fi�C+P PERMIT DATE: G s $t O l COMPLIANCE DATE: Separation Distance Between the: °uv^' a F P ecc Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on, site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY �. . �� z F o � � �,,.: �, z o �, �' o� r c. � i�' "�. — � c �' � t ` Z c� � S 1J � i `� C `�) � , d � L � ` _ � � v O = N w .� c�',to i No. Fee Do, THE COMMONWEALTH bF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Rpplitation for his osaY *pstem (Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 4J3 *,J A ie Owner's Name,Address,and Tel.No. Assessor's Map/Parcel N Y � S a 10—015 t -v e: Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. A lk'�Qvwa 7-,ac L.v 1NCc_v, W&,(VS s c3-4 -S-3I Type of Building: Dwelling No.of Bedrooms 3 Lot Size /6 7 7 G sq.ft. Garbage Grinder( ) Other Type of Building VI OVS C No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.recwired) `3 30 gpd Design flow provided '3�)�� gpd Plan Date 4 -2- 1 `') Number of sheets 2 Revision Date Title ` Size of Septic Tank y S 0 V Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Cd,\Apjp E-e syeS i--e_M 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. Signed Date Application Approved by 3,1 r Date Application Disapproved by Date for the following reasons Permit No. oLcltq —' lk Date Issued ~*� nn No. Fee t. THE COMMONWEA;L,nai, MASSACHUSETTS Entered in computer: Yes� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZipplitatIon for 13isposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(y) Upgrade( ) 'Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. W3 Owner's Name,Address,and Tel.No. layv,JN;S Del} ,[e Assessor's Map/Parcel 310-01,7 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 'L�c,vsv-s A t�)ivwa T..jc �;0�3 /C.U-7JS5 .v ►nJC c'✓ ( ✓res sC -531 J Type of Building: Dwelling No.of Bedrooms 3 Lot Size /6 7.7 sq.ft. Garbage Grinder( ) Other Type of Building Vt(7 u5 r No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 0 gpd Design flow provided gpd Plan Date �- I 1 `I Number of sheets 2 Revision Date I Title r Size of Septic Tank 1 S OU Type of S.A.S. S N_(�GM S 1�.BX 2Sx L Description of Soil S •� " Nature of Repairs or Alterations(Answer when applicable) /'�)nA p�P k e Sy e P M 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 Compl(,ance has been issued by this Board of Health. Signed �i d c_.�-- Date .20—/H Application Approved by Date (�"��L• 9Application Disapproved by Date for the following reasons Permit No. C'�,C4 "' V( Date Issued ------------------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by7P v S/G S A i3(v w nl /,J C at L l S wL.�i-v w A-y e_ 4 y a.NN 1 S has been const�c ed in aac�ctc,with the provisions of Title 5 and the for Disposal System Construction Permit No.(J{// d Installerj__),,uc�&% A Designer 5nJt ' /Lt�✓��'v< WUfGCS #bedrooms 3 Approved design-flow 3 gpd The issuance of t is p/e it h/all of be construed as a guarantee that the system w'h function as dessiigned. Date Inspector l -----------------r--(----------t ` -------------------------------------------------------------------- ------------- ----- No. o "1 �� 7 Fee ( Q " THE COMMONWEALTH OF MASSACHUSETTS- PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposat .6pstetn onstrnction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at q 3 W 0U 4 Noe �v ruunl t S f 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. e , A Provided:Construction must be completed within three years of the date of this permit. � / / p Date (� D � �7 f Approved by 06/24/2014 08:21 5084775313 ENGINEERING WORKS PAGE 01 'own of Barnstable Regulatory Services r Richard V. Scall, Interim Director Public Health Division Thomas McKean,Director 200 Main Street,Hyknmis,MA 02601 office: 508-862-4644 Fax; 505-790-6304 Installer & Designer Certification,Form Date: r`� S� Sewage Permit# 20 q-20 Assessor's Map\Parcel Designer: Installer; Xra��,-s ,ktie •.Address: Address: f-0, Lean. On -!' 1 was issued a permit to instal] a (date) (installer) septic system at �J 1�a � �`'� JkKL used on a design drawn by k�cl.e�r"T'"�mac,�,.r.�•c•e 'P_€, (a dress) 4V% ; n �rzr� n LNb�l�-r dated �' r (designer) V ] certify that the septic System referenced above was installed substantially according to -� the design, .which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) Was inspected and the soils were found satisfactory. 7 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. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constru with the terms of the]1A approval letters (if applicable) PETER T. CIVIL, - No.3810�4 stal er's ignature) ` (Desigzler's Signature) (Affix esigner's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTR DM- SIGN. CERTIFICATE OF COlY1PLTANCE )Ypt,L NOT BE ISSUED UNTIL BOTI3 I`$IS FORM AND AS- -RTnT CARD AM RECEIVED BY THE BARNSTABLE PUBLIC j�.AT.TH DIVVSSIO?,I, TLXNX YOU. Q,\scptiJ5esiper cemfication Form Rev 8=14.13.doc Town of Barnstable P# Department-of.Regulatory Services < ar Publ><c Health Di s><On- Hate A i63q.. d' 200 Main Str egHnin,,s MA 02601bate:Scheduled Te Fee Pd, Soil Suitability Assessment for Se e Dispo t Performed.BY. Witnessed By; LOCATION& GENERAL INFORMATION 1 Location Address Lt?J. wa��� A,-4 Owner's Name a 11 lav1 Vl �S K�� Address L(3 W_ej-E-0 n I��`e v�(4 G Assessor's Map/Parcel: a - Engineer's Name NEW CONSTRUCTION REPAIR Telephone# .15;a F--7 3 7 —Lf-7 64 Land Use �` 4"�"''i I of Slopes(%) �.7 Surface Stones /V Distances from: Open Water Body 'N ft Possible Wet Area N ft Drinking Water Well )5� ft Drainage Way ft Property Line 6f ft Other ft SKETCH:(street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands?n proximity to boles) - I , C ,0 cici i^> o I! M Parent material(geologic) elcice I �'�r`�`4 f it Depth to Bedrock Ai ' Depth to Groundwater. Standing Water in Hole: -1J Weeping from Pit Face Estimated Seasonal High Groundwater 2 % 3 t---- DETERNIINATION FOR SEASONAL HIGH WATER TABLE - Method Used: <' Depth Observed standing in obs.hole: __ __._In.- Depth to soil mottles; ,. In. Depth to weeping from side of obs.hole: in, Groundwater Adjustment it. Index.Well.# Reading Date: Index Well level,�, e,_,, Adj,factor Adj.droundwater level ,,,e, PERCOLATION TEST bate- Time. (Z Observation Hole# 2 Time at V Depth of Perc 3 .y t l c..S Time at 6" Start Pre-soak Time® Time(9"-6") End Pre-soak , Rate MindInch. Site Suitability Assessment; Site Passed t Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observtition 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:\SEPTICU'ERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture .Sdil•Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure;:Stones;Boulders: c6nslwgy, gravel) S c_ 3 S l c JZ. DEEP OBSERVATION HOLE LOG Hole# �-- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%z DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color ' Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,.Stones,Boulders, -.—consistency,%OGMell- 7 - e r Flood Insurance Rate Man: Above 500=year flood boundary N16_. Yes - Within 500`year boundary No_ Yes Within 100 year flood boundary No Yes Depth of Naturally Occurrine Pervious Material Does atleast four feet of naturally occurring pervious material exist in all areas observed throughout:,tha area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? - Certification I certify that on I,i 1��� (date)I have passed the soil evaluator examination approved by the Department of Environmental Protecdon and that the above analysis was performed by me consistent with . the required training;expertise and experience described in CMR 15.017. Signature t\/l_,. a Date—3—V ly �� Q-.\S•EPTIC%PERCFORM.DOC LEGEND N l x 100.98 EXISTING SPOT GRADE -- 98 -- EXISTING CONTOUR &.if w OVERHEAD WIRES 3� W EXISTING WATER SERVICE LOCUS to TEST PIT BENCHMARK L00.CP 17201 C N y �µpUS RD emu+ � v � cHEsrNur sr v p v CHERRY ST LOCUS MAP NOT TO SCALE I/ S 11*58'47" W . 100.01' chainlink fence II - 99.03 98.71 F_xX_ SHED w EXl APPR CESSPOOLS (APPROXIMATE)98,64 TO BE PUMPED, FILLED TP_1 0 I W/SAND & ABANDONED 98.?7 2--5..'��P_ 35, POSE, 5. I86 0 0 97.84 97. 0 x1 98.78 98,81 _ I x i 97. 2 r-' ,198 PROPOSED -' x 9 '8 BENCHMARK SET SEPTIC TANK o 0 0 1 OUTSIDE COR./BOTT. STEP x EL.=100.16 .98.22 98,87 (A BRI K I x -w BB 98.62 99. 5• x - -� 99.7 I (D .a N \� SPIKEI cat ONCRETE" Z i 98.56 PATIO':_ 99.73 U) f + �f f' 99.15 O Io _ENCLOSED o � _ _I _ PORCH 0 _ 98.96 ; '. m EXIST. SEWER IN =97.8' �� 98.66 m x ,EXISTING GARAGE �1 /. 99.56 HOUSE(#43) x 100.3 / x 98.97 x T.O.F.=101.2f / °' o + 99.88 � Q IRRIGATID! x ;'. 1 0.8 ? 100,5C� / 100,14 100.7 +�q�� I Z 0 L0CT C5 z M B L 3 0150 o ;��0056: I 1 •� , 0 a 16,77 SF a :h. • 99.39 Px ---'� ,m. p x x 99.94 99.76 99.91 O'kade fence 100.00' : �S 12* '19" W i SIDEWALK ~' PK SET _ 99.16 EDGE 99.49 OF 99.83 PAVEMENT 100.12 WALTON AVENUE O F M4ss9�yG o PETER T. PROPOSED SEPTIC SYSTEM UPGRADE PLAN M EE CIVIL N 43 WALTON AVENUE, HYANNIS, MA No. 35109 RE �0 �`� Prepared for: Paula Deitke, 43 Walton Avenue, Hyannis, MA 02601 GIST ER FS \` Engineering by: SCALE DRAWN JOB. NO. L OWNR OF RECORD 1"=20' P.T.M. 131-14 DIETKE, PAULA M Engineering Works, Inc. 43 WALTON AVENUE 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET No. 4'�A11A HYANNIS, MA 02601 (508) 477-5313 4/2/14 P.T.M. 1 of 2 NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL:95.5 FOR A DISTANCE OF 15' AROUND THE SEPTIC TANK PROPOSED D-BOX PERIMETER OF THE S.A.S. INSTALL RISERS & COVERS OVER INLET &OUTLET AND SET TO 6" OF FINISH GRADE INSTALL RISER & COVER PROPOSED S.A.S. SET TO 6" OF GRADE INSTALL RISER & COVER OVER EACH CHAMBER AND T.O.F.=101.2t SET TO 3' OF F.G. TO SERVE AS INSPECTION PORTS F.G. EL.=99.2t F.G. EL.=99.1 t F.G. EL=98f.0t F.G. EL.=98.0 .� . A . .AIA.Y.•�7a7ydOYJ aJ L = 35' 3'(max.) L = 9' @ S=1% (MIN.) ® S=1% (MIN.) p S== 5(MIN. 4"SCH40 PVC 4"SCH40 PVC ) 2" LAYER OF 1/8" TO 1/2" s"" 4"SCH40 PVC DOUBLE WASHED STONE ma U-ii0"1 " s 00B0 E30 (OR APPROVED FILTER FABRIC) 14" BBOE INV.=97.00 48" UQUID aaaaaaa -3/4" TO 1-1/2" DOUBLE LEVEL ADD 1�tINV.= PROPOSED 4' 4.8' 4' WASHED STONE GAS INV.=96.50 D BOX INV.=96.33 96 EFFECTIVE WIDTH = 12.8' 3 OUTLETS INV.=95.00 ED PROPOSED SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS SURROUNDED WITH STONE AS SHOWN CONNECT TO EXISTING 4" SEWER • AT H-10 RATED HOUSE AT INV.=97.87t(VERIFY) TOP CONC. ELEV.=95.8t NOTES: BREAKOUT ELEV.=95.50 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INV. ELEV.=95.00 mama INVERTS, PRIOR TO INSTALLATION. aaaaa aaaaa 2) SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND BOTTOM ELEV.=93.00 TRUE TO GRADE ON A MECHANICALLY COMPACTED 4' 2 X 8.5'=17.0' 4' SIX INCH CRUSHED STONE BASE, AS SPECIFIED 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.0' IN 310 CMR 15.221(2). PERVIOUS MATERIAL 5' (MIN.) ABOVE G.W. 3) INSTALL INLET & OUTLET TEES AS REQUIRED. LEACHING SYSTEM SECTION 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE BOTTOM OF TP, EL=87.0 46 AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. (NO GROUNDWATER) SEPTIC SYSTEM PROFILE �-- _--25.___-1 SOIL LOG DATE: MARCH 25, 2014 (REF#14,316 N SOIL EVALUATOR: PETER McENTEE PE(SE#1542) P OPOSED S. ;O WITNESS: DONNA MIORANDI R.S. HEALTH AGENT ELEv. TP-1 DEPTH ELEV. TP-2 DEPTH 98.2 A 0 98.0 A 0" SANDY LOAM SANDY LOAM 10YR 4/2 10YR 4/2 97.1 13" 97.0 12" p B B cp co SANDY LOAM SANDY LOAM uj 10YR_5/4 ". 10YR 5/4 Q) �. _ _ - - 95.4 34 95:0 -:.- 36 _- - - _- �0�' �, N C C PERC ® 36"/48" M-C SAND M-C SAND 2.5Y 6/6 2.5Y 6/6 87.7 126" 87.0 132" PERC RATE <2 MIN/IN. ENCLOSED NO GROUNDWATER ENCOUNTERED PORCH GENERAL NOTES: EXIST. SEWER INV.=9I 1 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. 2_ ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS ,EXISTING GARAGE OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS. HOUSE(1143) 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR T O.F.=101.2E TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE OR OWNER TOTHE LOCAL BOARD S.A.S. LAYOUT HEALTHO TOR FOR CPROPER INSPECTIONS OTIFY DURING CONSTRUCTION. OF 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. DESIGN CRITERIA 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS NUMBER OF BEDROOMS: 3 BEDROOMS AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0.74 GPD/SF) 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY DESIGN PERCOLATION RATE: <2 MIN/IN THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. DAILY FLOW: 330 GPD 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS DESIGN FLOW: 330 GPD IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND GARBAGE GRINDER: NO-not allowed with design REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. .74 GPD/SF 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM), H-10 RATED PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 2-500 GALLON LEACHING CHAMBERS IN SERIES 43 WALTON AVENUE, HYANNIS, MA SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: Paula Deitke, 43 Walton Avenue, Hyannis, MA 02601 BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. Engineering by: SCALE DRAWN JOB. NO. TOTAL AREA:.............................................................. 471.2 S.F. Engineering Works, Inc. N.T.S. P.T.M. 131-14 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD (508) 477-5313 4/2/14 P.T.M. 2 of 2