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Home My WebLink About0074 WINDSHORE DRIVE - Health LA 4 WINDSHORE DRIVE;HYANNIS= 271 154 . � y { TOWN OF BARNSTABLE Ld ATION .4s hor @ Dt it✓P SEWAGE # vgLLAGE WI/0 0lh i S ASSESSOR'S MAP & LOT �7 _ LNSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY t 00 0 LEACHING FACILITY: (type) 1Ul�t tit S (size) 1t X 36 l< NO.OF BEDROOMS BUILDER OR OWNER CICVSU I VC S PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If.any wetlands exist within 300 feet of leaching facility) Feet Furnished by C-C O' ,TPA 1 ti yor+ton !Ioog �, --- - 0-BOX LOCATIONS 0 = e (! LEACHING GALLERY I 38 FE 17 ft, - 2 64 FL, 64 Ft. SEPTIC TANK o i l e , EXISTING f DWELLING i # 74 W Z J � ' W F- NOT To SCALE WINDSHORE DRIVE , Y No Fee « / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,MASSACHUSETTS ZIppliCAtion for 30i5pooY bp$tem Construction Permit Application for a Permit to Construct( )Repair(�pgrade( )Abandon( ) El Complete System L7I dividual Components Location Address or Lot No. _� Lt wA4 J „C y, Owner's Name,Address and Tel.No. Assessor's Map/Parcel r 14 YA-vt�I Z0 t�— C NC,4 w� Installer's Name,Address,and Tel.No. Designer's Name,Address�d„—Tel.No. ct Type of Building: Dwelling No.of Bedrooms Lot Size l 3� OVosq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 O gallons per day. Calculated daily flow 3 it-7 gallons. Plan Date /0 /7/0-5 - Number of sheets Revision Date Title Size of Septic Tank �� Stt/ Type of S.A.S. - �-T h J Description of Soil; J'�- 4&'n If Nature.of Repairs or Alter ions(Answer when applicable) �' c I"P r lel [�OD w �f y 6 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 iss y this Board of Heal! . Signe Date Z Application Approved by Date Application Disapproved for the following&ns Permit No. Date Issued nra ------ -- - - - — --------------- No. Fee /�— THE COMMONWEALTH OF MASSACHUSET8Q� i� Entered in computer, �f Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication far--Migpont *pMem Congtruction Permit Application for a Permit to Construct( j Repair� )Upgrade( )Abandon( ) ❑Complete System Individual Components Location Address or Lot No. (�i , J P D Y Owner'sName,Address and Tel.No. Assessor's Map/Parcel YA-1 O N Installer's Name,Address,and Tel.No. [� Designer's Name,Address and Tel.fNo. 1� rl� V� i lsi (/11/ a fat c�rJ ro dam- Y 2 , - 7 76 Z Type of Building: Dwelling No.of Bedrooms Lot Size �� OvVsq.ft. Garbage Grinder( ) . '- Other 'I�pe of Building No.of Persons Showers( ) Cafeteria( ) .Other Fixtures Design Flow 3 3 O gallons per day. Calculated daily flow J 7 gallons. Plan Date 0 3 A) S� Number of sheets Revision Date Title Size of Septic Tank //TDC� 4a Type of S.A.S. N 70 ,('014h Description of Soil f V-9/a,& , Natur of Repairs or Alter tions(Answer when applicable) "tIQ&(P rlei Pot ��.�G�`��r y 1 , y o'l I dfr>� a /� � d /PI) 7 G ' X /G , A le r~L t^ -(,- e_� r ti — Xxo S,/Z".p c,L4 c Gem G7 P e, . 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 is .e- by t 's Board of Heal . Sign ! o Date/O r7 Application Approved by " r Date Application Disapproved fort /t�� U f e following ea ons y , Permit No. !n� 2 Date Issued v_ - --=-- --_--- - -- 1 THE COMMONWEALTH OF MASSACHUSETTS 0 A BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO C Y, th; the 0 -site�S wage Disposal System Constructed ( )Repaired(Upgraded( ) Abandoned( )by /G s 45fGurn/ at 7 A,-i in eU X been constructed 'n accordance with the provisions of Ti e� and the for Disposal System Construction Permit No. datedd Installer Designer The issuance of this permit shall no be construed as a guarantee that the system 011 fu c i n as designed. Date O 1 �`� Inspector ---- —— — ---' No. � =— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS nigPogar *pgtem itCongtruction Permit Permission is hereby granted to Construct( )Repair(,I- pgrade( )Abandon( ) System located at G✓t n cIV--l-e � a," 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 must a co .pl t 6 w�it�j' three years of the date of t(hiig-pbrmiit. Dater �f../��/ Approved by V / U,l .% -f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage /D/isposal System Form Not for Voluntary nAssessm ents / 7 �✓1��f �Or� .C�11 v`� ftperiy Address 14 aa a v1 p I�G Ow ner Owner's Name / A informations requaed for every frown State Zip Code Date of YsPWW per- Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checidist at the end of the form. 'Po" A. General Information fffmg°` use only thetab 1. Inspector. key to move your cursor-do not G✓/+' use the non key. tsars of trmspedar Z ItIvf Company Name Comparrycb* Zip 1 Ckyfrown ,� po, �j�7 yd - Code Telephone a / / License N�anber .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 DIP approved system inspector pursuant to Section 1&340 of Title;"OR M000). The system: Pie ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Ins s SignatLre 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 DER The original should be seM 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 a future under the same or different conditions of use. Title5ofodaiimpeegmFartSubaxfweSewagel S. Rage1 17 >"M-M3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DQs al System Form-Not for Voluntary Assessments 2 Z c%� C15 4ar-e- .D- Avperty Address ON rs;r ON Hers tine / �� 6 O I ! d Sfforrre is rfultiredfo a 0 48 S forevery clyrrown State Zip ODde Date of kispeoft B. Certification (cons.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System saes: 17. 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 reed to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Heaith,will pass. Check the box for"yes° .°no°or°not determined"(Y,N, ND) for the following statements. V"not determined,"please ex0ain. 1. The septic tank is metal and over 20 years old'or the septic tank(whether metal or rot)is structurally unsound, exhibits subs aantial infiltration or efittration 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 willl pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 yeas old is available. ❑ Y ❑ N ❑ ND(Explain below): Y �3 rft 5officid ftpectw Form Subwfwe Swa%e D4csd Syom•f��e 20f 17 t Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal Sys�tem� Form-Not for Voluntary Assessments Roperty A �k--e-/ Ow rrer Ow rWs Name information is6 0/ 02. l requsedforevery av►N rt Oate ins Pap. C$y/Town state Zip Code PWW B. Certification (conL) ❑ Pump Chamber Exurips/alarms not operational. System will pass with Board of Health approval if pumps/alarms are refired. B) system Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distributes box due to bmken 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 N(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain mow): ❑ 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 1&303(1)(b)that the system is not functioning in a mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water Cesspool or pr ivy is within 50 feet of a bordering vegetated wetland or a salt marsh ❑ nae s officia kspeaft Form SUMAIMS 59VA8e 0isposd Symm•Page W 17 t5m•3M3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-/Not for Voluntary Assessments If rr d s Gt arm ��/•� Property Address Ove Ow ner oa nees gamerecpjW forevery City/town Sbbe Zip Code Date of pec' n B. Certification (cons.) 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 tarn 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 f W cdilaorm 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 ❑ LJ' 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 SAS or cesspool or clogged pool ❑ Liquid depth in cesspool is less than 6°below invert or available volume is less than day flow t5ns•3f13 TileWfidal bspwfionk rmc Subwface S9WW DLVWd SyMm•rte 4of 17 r Commonwealth of Massachusetts MMMIa Tine 5 Official Inspection Form Subsurface Sewage Disposal System Form J-Not for Voluntary Assessments W1Hds)ior'e. Wit R`operty Address Low / Ow nor Owner's Narne iefonnatim is I- a n 4/ Oa r for every Clyfrown State Zip Code Hate ofpage- �spection B. Certification (cons) Yes No ❑ Required pumpi rig more than 4 times in the last year NOT due to dogged 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. ❑ Arty 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. ❑ LB 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 acceptabe water a quality ceanalysii�eds. �is system passes if the well water analysis, performed 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.] ❑ e 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 CHAR 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 faciflty 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 signif ant 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. t5m 8n3 TMOSO "hmpecbwFarm Sub=1aea8a%%aDLq)M l Stem-Page5orl7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments / � L✓i��,s[2 orb �� Property Address ON ner Ow ro's Name eifomration is / r�equh forevery nrf page, Ckffrown StafiE zip(:ode DaWof lisp tan 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 ❑ Were any of the system components pumped out in the previous two weeks? ❑ 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 13 thus inspection? Were as built plans of the system obtained and examined?(if they were not available note as WA) 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? ❑ Werethe septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)projded with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soll 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(" D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): SM•M3 Title50 ftW 1M;-timFar[SubSWSCe SOVageDi P=9$YASM-Page 6Or77 Comrnonweatth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Forth-Not ibr Voluntary Assessments Pmpertynddrew Ow ner o v nees Name infonrad t is 4,f °.)-e o 7 A� regtdredforevery State zip Code Date Ns* per. dylrown D. System Information Description: a 6"�r o-7 Number of current residents: Does residence have a garbage grinder? ❑ Yes '"" Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes 0--No Seasonal use? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): Detail: Yes ET'u- Sump pump? Last date of occupancy: Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(teased on 310(DUI R 15.203): Get=per day(gA Basis of design flow(seats/persons/sq.tt., etc.): Grease trap pres ent? ❑ 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: tsar•ans rftsOfkadhspeMmFtrmSUb=face mien•Page Hof» Commonwealth of Massachusetts Titre 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments/ `K (.✓ih d S4or'c. ae-- Address � pv� owner oarat N=infonre �,,¢ D�6 o I ld ton's yJ A r!n I S regWredforevery (�y/Town State Zo Code pets of hts n Pap- D. System Information (cord.) Last date of occupancy/use: pate Other(describe below): General Information Pumping Records: 2�✓S� Source of intrmation: Was system plumped as part of the inspection? ❑ Yes If yes, vol tone pumped: ganom How was quantity pumped determined? Reason for pumping: Type of System' Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if arty) ❑ Innovative/Altemative 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 UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): rmesot5eaiImpm5m Form Sub%gfaeeS9vAQ9MgMMSYSWm•Pape$017 15rt•3H3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage/'Disposal System Form-Not for Voluntary Assessments Pto / T Wi h cisna✓�C �/'� �Y� - perty Address ply l Owner ON ner's Name infomadon is �a 6 O J reQiMforevery State Zip Code Date kapeollm pW. Cily/Town D. System Information (coat.) Approximate age of all components, date installed(f known)and source of information: �— Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): . O Depth below grade: feet Material of constructi;�40 [I cast iron PVC ❑ other(explain): Distance fr=private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material truction. mcrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I tank is metal, list age: years Ls age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: •3fl3 Title5otkisimpec5anForm 8oCsvtaceSewageoisposal System.Page9017 Commonwealth of Nlassachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth Not for Voluntary Assessments Property Address ,LOP-e`l owner Owner's nw,e 0�6 0 19 1 information's cti vt��I reqWred for every /4drown State Zip Code Date Ins n PW- D. System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness A Distance from top of scum to top of outlet tee or baffle N Distance from bottom of scum to bottom of outlet tee or baffle J o le How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, stnckuvt integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): (mot v"i i✓l 0,9/ 14-ee cJe� 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 purn ping: Date ens•sna Title 5o;8w 1mpec#MFam SubMIMO SOVAMODPMd SOM'P496 104 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �� C✓,� �s �a� D� W tier Qa lids Name �� Q�6 0 etfornratiori's RN�1 r1 requvedforevey Ctyfro n state Zip Code of PW D. System Informalion (coat.) 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{tarn must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of consbwtion: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: Peons Design Flow. ga®ons per dw Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: pate Comments(condition of alarm and float switches, etc.): •Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5M•3H3 Tice50f5ad 6spwboFmrt Subartme9WMq9DWp0SdSYslam•Pap 11 d n Fa s Commonwealth of Nlassachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments Roperty AddressOMM informat�n is 7ne Name ✓► Zi Codepate of peCrequiredforevery n f�• D. System Information (coat.) Distribution Box(f 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 ranyover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): ❑ Yes ❑ Pumps in working order. ❑ Yes ❑ No' Alarms in working order 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): I SAS not located, explain why: TWe50f5dd jmp9dwFem[SU1''face sewgeDLcposaj system-Page 12 of 17 15m•Y13 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �� C✓,i ds 4a>� a- �Roperty A o� l ow ner ON nees game doZ 6 01 C T/�fomg6on is P(,7 aO H iJ 02 �forevery /Town State Zip Code Date hspecOon D. System Inbrnriation (cont.) Type �-✓� !/�l�ra7o�f `-�LOohe �/ �6 x ❑ leaching pits number. ❑ leaching chambers number ❑ leaching galleries number. ❑ Teaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number ❑ inrrovativelalternati%e system Type/name of technology: Comments(rote condition of soil, signs of hydraulic failure, level of ponding,damp sal, cor dt!on of venation, etc:): o�t2 cH� 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 groundarater inflow ❑ Yes ❑ No tam—= rite soEfidal tmpeck Form Subarface Sw ageMpwd SyMm-Page 13 d tt Commonwealth of Massachusetts mor-2�ia W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-r Not /fbr Voluntary Assessments T �✓1 d ,s�lOi^� /c// Roperty Address Wwner Owner's IVarne i �j 0"1 601 a�Ar— reqWredforeveryinforn�rons vt t9ll Pap. tayfrown State Zip Code Date D. System Inkrmaiaon (cons) 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.): tars•3n3 Tl9e5Of dd hspec9mForm Suhsuface SwfigeM9xsal System-Page 14 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 'Subsurface Sewage Disposal System Form-IINot for Voluntary Assessments- / Property Address L/ / a of 4/1 � DylC l Ow nor Qn ner's Name 'l regWr dfo is Od 6 0 I r+equaedforevery '�ti �f PW. CAy/Town State Zip Code Date of hs tion D. System Informalion (cons) Sketch Of Sewage Disposal 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 p Ic water supply enters the building. Check one of the boxes below.. hand-sketch in the area below drawing attached separately , l a FR o ti T /4/ 3� rare•313 Title50fktd hspmft Fomc Stjb=face Swj geDi cad System-Page 15 d 17 �. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �� /r✓1�s ort Reperty Address LOve ON ner Our ne's Nm a kdon ation is Ar / ' (o b/ 02 7 r' regWredforevery c Nown State Zo Code Date of bspeclim D. system Information (cost.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record if checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Cyr Checked with I oard 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: /0 !/YC L✓. 0 0/IJ�7�✓t-�- 6. / a lot,S�4 VI'l Before filing this Inspection Report, please see Report Completeness Checidist on next page. L4�B,3H3 Tft50ffad trtapw§mFamt Sufi fam SewageDiq=9 Spbm•fte 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurbcs Sev ageDisposal System F oam-Not for Volurdary Assessments /�/ Rbperty Address �0" / ly Owner Owner's Nwm WamlarAn is mqtdWfbrwery 141:A- oo-(w YA A 5 7 park :Cdyrrown ste Zp code Date of kapec im E. Report Completeness Checklist "Pection Summary:A, B, C, D,or E checked td" hspection SLffnmary D(System Failure Criteria Able to All Systems)completed �d Information—Estimated depth to high groundwater y tof Sewage Disposal System either drawn on page 15 or attached in separate ille t5a+a•sns TiW50ffiW kwP9 MFC=SAUN O&WPDtsPWd sPm•rinse 17d 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information 1 I on the computer, use only the tab 1. Inspector: key to move your p cursor-do not Ricky L. Wright use the return key. B & B Excavation,lnc. Company Name 14 Teaberry Lane Company Address Forestdale -MA 02644 City/Town State Zip Code P - 508-477-0653 S 14595 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3/3/12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. JA j0bj - t5ins•11/10 Title 5 Official 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 M 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 page. CitylTown 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 p 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): I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 ass unless Board oa d of Health determines in accordance with 31 C Y p 0 MR 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-11/10 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 M 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 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 aseptic 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 ❑ ® 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 page. City/Town 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 I ❑ ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage n/a 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: n/a 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information 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: 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) I ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank is original to dwelling S.A.S. up graded in 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection, building sewer appeared to be in good condition with no signs of leakage. Septic Tank(locate on site plan): Depth below grade: 1 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: 5.2x5.2x8.6 Sludge depth: 6" t5ins•11/10 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 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 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 31" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15 How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good working order, tees present no sign of backup or deteration. 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: 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.): i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No j t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 page. City/Town 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 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 time of inspection d-box appeared to be in working order no sign of carryover or detertion. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: infiltrators11'/31'/10" ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appeared to be in good working order. 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•11/10 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 °M 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 -Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information i e required for every Hyannis MA 02601 3/3/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cone.) 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 ❑ d rawi ng.attached separately T301C fAm o>rc B �3c ri H i�� t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 page. Citylrown 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: >120" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 10/3/2005 If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) k ❑ 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 74 Windshore Drive Property Address Bank Of America Owner Owner's Name information is required for every Hyannis MA 02601 3/3/12 page. City/Town 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1 'Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments nn- V)/ ,-74'Windshore Drive ; �? 4 t�.5��n Property Address Andonucio and Maria Gonsalves Owner -_Owner's Name t information is required for -Hyannis_-- -1 MA 02601 May 22, 2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: 1 ', only the tab key t to move your David D. Coughanowr t cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name 43 Triangle Circle Company Address Sandwich MA 02563 �fiOD Cityrrown State Zip Code 508 364-0894 1328 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 inspectionhe it pection was performed based on my training and experience in the proper function and maintena6'de of An site sewage disposal systems. I am a DEP approved system inspector pursuant tq Sectio 15.340 of Title 5 (310 CMR 15.000). The system: =A -s =,», OD ® Passes ❑ Conditionally Passes ❑ fi s ® ❑ Needs Further Evaluation by the Local Approving AuthorityTU n t rn May 22, 2008 = �\ Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the --. report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5-2941.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments qM a`'v 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner Owner's Name information is Hyannis MA 02601 May 22 2008 required for Y Y 4 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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 r ' 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. e9 *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. ND Explain: I 1 UtA ❑ 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 ❑ obstruction is removed t5-2941.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner Owner's Name information is Hyannis MA 02601 May required for H Y Y 22, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: 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 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. t5-2941.doc•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner Owner's Name information is Hyannis MA 02601 May 22 2008 required for Y y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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. t5-2941.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner Owner's Name information is Hyannis MA 02601 May required for H Y Y 22, 2008 every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. El 2 An portion of a cesspool or privy is less than 10 y p p p y 0 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 I I 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. t5-2941.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner Owner's Name information is Hyannis MA 02601 May 22 2008 required for Y Y every page. Cityrrown 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 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? Outlet only ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5-2941.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner Owner's Name information is Hyannis MA 02601 May required for H Y Y 22, 2008 every page. City/Town State Zip Code Date of Inspection 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 gpd Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 177 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current 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: Last date of occupancy/use: Date Other(describe): t5-2941.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner Owner's Name information is Hyannis MA 02601 May 22, 2008 required for y y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 2+years. Certificate of Compliance issued 10/1112005 (Board of Health permit#2005-500) Were sewage odors detected when arriving at the site? ❑ Yes ® No 15-2941.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner Owner's Name information is Hyannis MA 02601 May required for H Y Y 22, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling was observed. Septic Tank (locate on site plan): Depth below grade: 1 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: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 6 in Distance from top of sludge to bottom of outlet tee or baffle 28 in Scum thickness 4 in Distance from top of scum to top of outlet tee or baffle 8 in Distance from bottom of scum to bottom of outlet tee or baffle 12 in I How were dimensions determined? As built card t5-2941.doc•08/06 -Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner. Owner's Name information is H annis MA 02601 May 22, 2008 required for Y Y every gage. City/Town 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.): Pumping not required at this time but maintenance pumping is recommended within one year. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Inlet cover is under deck and not accessible. Presence of inlet tee confirmed using digital camera. 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.): 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): t5-2941.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner Owner's Name information is Hyannis MA 02601 May 22, 2008 required for Y Y _ every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At outlet inverts 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 appears structurally sound with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2941.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner Owner's Name information is Hyannis MA 02601 May 22, 2008 required for Y Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down into the leaching gallery. t5-2941.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner Owner's Name information is Hyannis MA 02601 May required for H Y Y 22, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): t5-2941.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner Owner's Name information is Hyannis MA 02601 May 22, 2008 required for Y Y every page. Cityrrown State Zip Code Date of Inspection D. System Information cont. Y (cont.) Sketch Of Sewage Disposal System: Provide a Sketch 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. D-BOX m m LOCATIONS LEACHING GALLERY A B 1 38 FL 17 FL 2 64 Ft 64 FL SEPTIC 1 TANK ° 0 B A EXISTING DWELLING # 74 W Z J W H 3I WINDSHORE DRIVE NOT TO SCALE t5-2941.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Town of Barnstable ��ftHE Tp� o Regulatory Services „ ,STABLE ; Thomas F. Geiler, Director - 9`� Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIC\Disclaimer Private Septic Inspections.DOC i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Windshore Drive Property Address Andonucio and Maria Gonsalves Owner Owner's Name information is Hyannis MA 02601 May required for H Y Y 22, 2008 every 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 ground water: 25 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: 1014105 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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 6.7 feet above the bottom of a witnessed test pit in which no water was encountered. Town of Barnstable GIS Department records indicate that the property is 25 feet above groundwater table. 15-2941.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 cellar at 74 Windshore ake 51 opening here disconnect all plumbing and kitchen chan n-ezi 27 11' 5 9- b ath kitchen II =+P'aPY aara a §` g 9 r '2::2' 'L��•� �3=»• N storage laun m bed I x4 . 0 stairs down ma 5`opening here a _t 9 ' 49'-2." kitchen bed b bath gaarage 21=4" N n7 - cV a N live bed N O stairs down Town of Barnstable °FtHe, Regulatory Services Thomas F. Geiler,Director + BARNSTABLE, ' MASS. `0g Public Health Division ArEo ►'�°i Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 1 d b s, Designer: 64,eA, t-: � � Rd. Installer: + Address: e4o. Opi e L w Address: WI o6% J{mJ 1010 /t/l-v u y On 6 b �. A, !, was issued a permit to install a (date) (installer) septic system at W'hcf J �A-- , f{YR,.h; S based on a design drawn by (address) �i(,ew �• �,�•s dated (designer) 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. 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. 11A OF GLEN 9�yG ( aller's Signature) HARK IIGTON No. 1070 (Designer's S a e) (Affix p 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. Q:Health/Septic/Designer Certification Form . r • 'i Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only s PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM J �r I, �lCr►E• t ��, ,hereby certify that the engineered plan signed by me dated /v 3 0r concerning the property located at 7 Y k11 w d 1 k±n9,)K, L4A4 I,7 i Y meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering)and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances.requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top!'of Ground Surface Elevation(using GIS information) __ B) G.W.Elevation +adjustment for high G.W.Cv•y = a y DIFFERENCE BETWEEN A and B ' G SIGNED : DATE: NOTICE Based upon the above information, a repair permit will be issued edrooms maximum. No additional bedrooms are authorized in the future wi out engineered septic system plans. gASeptic\percexemp.doc AsBuilt Page 1 of 1 TOWN OF BARNSTABLE nn LOCATION 7 'A5 hyr e Vb r✓e SEWAGE # VILLAGE_ kyrd whis . ASSESSOR'S MAP &LOT Z-7(' 5 INSTALLER'S NAME&PHONE NO. i SEPTIC TANK CAPACITY (00 0 II LEACHING FACILITY: (type) c ati 1�VGt�Of (size) tt X, 36 F, NO.OF BEDROOMS,_ �L ! BUILDER OR OWNER C�d+SG1G✓��_ PERMPTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility' Feet i Private Water Supply Well and Leaching Facility (1f 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 . n-eox i Cam] Z LOCATIONS A' B LEACHING GALLERY l 38 2 64 fk 64 ft SEPTIC TANK .. A EXISTING DWELLING # 4 • ;f I WINDSHDRE DRIVE NOT TO SCALE http://issgl2/intranet/propdata/prebuilt.aspx?mappar=271154&seq=1 2/22/2012 LO-C A T-1ON +14047L/ SEW A G E PE RMIT NO. VILLAGE IN'STA LLER'S NAME & ADDRESS 75, I C, B UI'LDE R OR OWNER l CA D e f [ � DATE PERMIT "ISSUED _ � �_ 77 DATE CO-MPLIANCE. . ISSUED i i ' �l� � J ...tom `� / V �� -� � �6. �,, �. . f. ly THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J ._V- ---------------OF........ Appliration for DispatiFai Works Tomitrurtiuu Prrutit Application is hereby made for a Permit to Construct ( L-)-or Repair ( ) an Individual Sewage Disposal System at ........ ... Y'-'•"f..................... .......... ... ' .. ..... ,(aa, n-Addu, 74 19/ (qr Lot N6 ----^^�------•-----e16 :_.--....la(JGs:<r... ..50?......................... .•---..._...�. I!.�,C...�r:., ..X.----•-----.........------............................... Owner Address W Installer Address Type of Building Size Lot...1 ,e____________...Sq. feet U g— .Expansion Attic ( ) Garbage Grinder Dwelling No. of Bedrooms___________ _________________________ aOther—Type of Building ............................ No. of persons...... ..................... Showers ( ) — Cafeteria ( ) Q' Other fixtures .......�/P1t?'p.................. W Design Flow..........$-.5........................ gallons per person per day. Total daily flow---------------2�®.................gallons. WSeptic Tank`Liquid capacity gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width............ T tal Length.................... Total leaching area..................:.sq. ft. Seepage Pit No.10,�6-_;tt_/_ Diamete[ftwie_ i below inlet.................... Thal I thing area....41a.7..sq. ft. Z Other Distribution box ( ) Dosing to ( / - /2- 7-7 ' C ... Date ..... 77......_--•--- a Percolation Test Results Performed by__.__.. -.....�, ....... Test Pit No. I................minutes per inch Dept, of Test Pit................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O — 2 rL r. . n r... ........ x Description of Soil----------�----.. ...,,a....... .... ...........9CS.?.r�_..---------------2-�..[�--�"---��'� --t`�-------- -- -1 - --------------------••--• -•••••••---•••....•---••••••••---••-•-•••••-••••-•-•-••••••-••••-•----••--••......••----•..... w UNature of Repairs or Alterations—Answer when applicable-------------------------------------------------............................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signe d,- ° i � ... .... Date Application Approved By-••.--- •••• .••. -• • • •-•-•------------------ •-• Date Application Disapproved for the following reasons: ==-=------------------------------------------------•-•-•-•••••• ----••......-••••••-••-•...... .........................................................-•--------•---------------------•-------•----......•••-•-•-•••--•••••••••••••••••--••••-•-•--------•--••-......-•-••----•-••-••••....---••- Date PermitNo......................................................... Issued-....................................................... Date F.3y No......................... . ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4 ..........._....OF......- `�e�f.......................................... Appliration for UWoiial Works Tonstrurtion "amit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Syst of,................................................................ 2 _. .42 V C�Z �r ----------- ............................ .......... Ad4fe"ss . Irr.Lot.No....................................------------ -----7- . ........ .. ------------------------ ....... OwnerAddress �,I�....................................................... ............................. .................................................................................................. -N Installer Address Type 'f'B i ing Size Lot--- ----Sq. feet ................................Expansion At-,tic,(j, 3 Garbage Grin 0� wet Jtrig n .,k`6. of;Bedrooms....... der Showers Cafeteria Other Type of Building ........ No. of persons_ fixtures ---------------7.............................................................................................. ........................................ Design Flowy.'.......... _r-------------_-------gallons per person per day. Total daily flow......._ AiF!-_0.................gallons. pacl -Depth................ 1:4 Septic Tank-4tiquid�ca allons Length................ Width_-------------- Diameter---', A,4! Disposal Trench—No. ............ T tal Length.................... Total leaching area___-.---_---------sq. ft. below inlet.................... Total leghi 41A7.-sq. ft. Seepage'Pit No, PAV_�*: Diametq�N -------1_*_4)T/'_1 ing area._. P`ercola Z Other Distribution box Dosing tank *7 ion Test Results Perfot D A�n.77...........by........ Depth"-th Test Pit No.'I................minutes per inch Depth of Test Pie.................. ep to ground water.___.._....._.........__. Test Pit No. 2 .... ._._....minutesper inch,, Depth of Test Pit.................... Depth to ground water........................ P41 ................................ ------------------------------- -------------------- 0 Description of Soil................ ........................... -,I/........................................... .......................................................................... U ------------------------------------------------------ --------------------------------------------------------- ...... ................................................................. U Nature of Repairs or Alterations=Answer when applicable........-------------� .......................................................................... ..............I_............. ......... ...................:....................................................... ��..................------ ---------------------------- Agreement: The undersigned aforedescribed- Individual Sewage Disposal System in accordance with the provisions'bf`2,114PILE7 5,of,the State Sanitary Code— The undersigned further agrees not to place the system in operation until a C.ertifipate of Compliance has been issued by he board of h all h. Sign ..... .... . . . . ..... ...... ------ -- 41 Dat e Application Approved By___.__- ................. ....... Date V Application Disapproved for the following reasons:.......................... .................................................................................... ...................................................... ......................... ------------------77 77-----------------------r---------------------------- --------------------- ,7 'Date Permit No............... . Issued ............ ....................... Date THE—C-0- M6 I�WEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ....... ..................................................... wrtifira ToU41fiatta THIS IS TO CERTIFY „That the Individual Sewage Disposal System constructed ( o* r Repaired by............... I -------;7--- '71,77,17" Instal I , ` ----------------- .... ........—----------------"---------------------------------------------------------------------- a�4 3.4.................. ................................ ................................................................................ has been installed in accordance with the ii O. 'sion's--of TIT 5 of The State Sanitary Code as described in the application for Disposal Works Constructi T d-------J.1".n--- .............................................. date THE ISSUANCf. OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE ;.t I I� SYSTEM' WILL FUNCTION-SATISFACTORY. DATE...........t7............. ... tf �a .......7. ................................. Inspector------ ...................................... THE COMMONWEALTH OF MASSACHUSETTS v BOARD PF HEALTH 3y ....../V .............OF....?&10 No......................... t FEE---.................. Disposal World Tonstrurtion "Prrmit Permissionis ereby granted.-------- ............................................................................................................................ o,t Ctract. r� ), o r e p . Hual Se age-Disl)oAl System , om R it anAdivi. w 1 4 at NW....cA 6.4' 71 _PX��................................. lorp 14r -'7Streetx, - - ------------------------------------------------------------ .... ....... as shown on the application for Disposal Works,Construction Permit Na__________._........ Dated......... . 7 .......... ............. .............................. Board al ealtt-,4— DATE............................................................................... V FORM 1255 46SES & WARREN. INC., PUBLISHERS �'Stttynl� F�ntl..�( :�3-.'E�1=venoac i ' � {- � ,� . �,� � �•� :�, '. -' y L10 GArzF-*.N e Grzl t-tca '�` f �� " I £s,l o• bAtL� t~Low 1tb x 3 t 3�b G,PD. , �. :� - f � _t • F 1 1 15 0 % • AIDS USA- tI>OC3 6AL. 20 j .: R KP _ '.. j2lSP0SA.L .PIT USE. loco GOL„ ' d• `� SCLcwALL Atzl✓A - l5o S.F. t '; • , t �75 P IT.. 1•.f 1' 0 QD 1 Tcrr,&L 'fl SS16W z d2S L .P.U. �.:.�w ' .'! ►y 1 TANK' L T FDW MlZGDLQTloLJ 04TE S 1°,10 2-mlo 02 f v� • Q t i Nf OF Ergs o s� tN F v RIC IARD 1 A �Y �� AL •.N 'Q BAXTER u .o •� s r . � �-, a •, a j No.2410 (M8jo, r t t �' f SUM i `:S, � t • 1. tom. � ..} .r }..�. {:,�.. ,..; R9.0 Top 1=°•+0 0 C17.0 .. a 7, ,P sDgaoil. 4�Apr Wit: Ilft/. 6 AL. TI 9G.7a GG�.R6 b r -Box 9G•4 SEPC 111LP. ° IAlV. l 'Thh1K .. to SAND ioo0 s•7 IN IIN ; �. GAL. 9G a 9c.� �• LeAaq PIT . , l0 i NONE 8q. 9� IG 6�AvCL• ' C-SZTtt=1-ELD.' pLC>-r PL./AL1,I LOCATIOW N �1 A N N 1 S, M 12 B6.a lJo ,A0 0/ I L� �7 No k1A reg. 1 CGtZ'['I��f 'f '-(AT TI-lCc D l WSLOAG °5140VJ pt-AV11 V-GP--V-a► ica ti-IC:P_t_t51J G��rlPl.�(S W 1 TI•� TIaC �1 II�..t_I�C-. � `.,d�(" Z3 Auu tf�C'reACV- C'c4UlQc : AA� uTs of TNc_: t_;..c. 3 -7 c. �• p Io IZ 1 n W A 7 t ��•��G�c��.�! � _._._.. .._._. L3/S.XTC,tZ. < . 1�1�(C_ I�G. 1 t2CGl; tt�tzt.=.D 1�LtU SUCv�.YoI�S 'Tt-tl�, I�r•.A1-1 1--4 LIOT v�..l 1!•�� '�?/.1/✓'1,1••'.,b•1'(" ��t.Jt•'�/l=.:�( '1"I•It�; c71=t:',i::f"i :cl•1rs�.lt.�:� ' .1,. `- ,t �' Al,�twtal^r�.�•.,:! CAp , wine. PevVI Co 14,:W [:li1ll 05(o.;) ,.Io 17ctoy -:-I- ✓lI►!l': I, i( i..t l••t�" _.. .. TOWN OF BARNSTABLE LOCATION C sJ 0 �`�U � SEWAGE # VILLAGE Ire^�� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. Elm, SEPTIC TANK CAPACITY Znf:�[) U LEACHING FACILITY: (type) _U:tna J ' f-S (size).1 A,7(hX ZD` 60 NO.OF BEDROOMS BUILDER OR OWNER et?ERMTT DATE: J / COMPLIANCE DATE: 'U d Separation Distance Between the: sec Spf uu,- 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) /j Feet Edge of Wetland and Leaching Facility(If any wetlands exist r� within 300 feet of leaching facility) 1`\ Feet Furnished by '-L® —J saw f�I N SITE PLAN Design Calculations SCALE: 1"=20' Number of Bedrooms: 2 Existing Garbage Grinder: NO, GRINDER NOT ALLOWED WITH THIS DESIGN 0 BENCH MARK T Top OF CONCRETE BOUND U".-100.00 (ASSUMED) Septic Tank Capacity Required: 330 gpd X 200% = 660 gpd EpN Septic Tank Provided: EXISTING 1,000. gallon Leaching Capacity Requd: 30 74aGaIMIS R V)Leaching AreaRequired ire3303Gal-Ga0q.Ft.)=446E Sq.Ft. Existing Leaching Structure: 6X6 LP, TO BE PUMPED & REMOVED 7,V Proposed Leaching Area Provided: 36' X 10.83' X 0.83' = 467 SQ. FT. Total Leaching Capacity. 345 gpd > 330 gpd. reqd. S ITE Paved GENERAL NOTES 1011417' "HYANNIS" O 1. ADDRESS: #74 WINDSHORE DRIVE awes 01 2. ASSESSORS NUMBER: 271 154 LOCUS �Q 3. DEVELOPER'S LOT: LOT 23 4. TOPOGRAPHIC INFORMATION WAS COMPILED FROM AN NO SCALE x CD fnd' ON THE GROUND INSTRUMENT SURVEY. 5. TOWN WATER IS PROVIDED TO SITE & SURROUNDING PROPERTIES. 6. REFERENCE PLAN: LAND COURT PLAN 37666A, SHEET 2 OF 2 TH #1 7. NO WETLANDS ARE LOCATED WITHIN 200 FEET OF SAS. 8. NO POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS. 9. THIS PLAN WAS PREPARED FOR THE SEPTIC INSTALLATION ONLY. krsr�nc 0�* CONSTRUCTION NOTES *eWAIG B.M. fullfor 1. Contractor is responsible for Digsafe notification and protection of all underground utilities and pipes. 2. The septic tank a distribution box shall be set x 0 level on 6* of 3/4 -11/2 stone. IT 3. Backfill should be clean sand or gravel with no 0 a.JQ '^\ stones over 3" in size. J. 0� 100W 4. This system is subject to inspection during installation by Glen E. Harrington, R.S. 5. The contractor shall install this system in accordance 36'L X 10.83'W X 0.83' D with 'Title V of the Massachusetts Environmental Code LOT 23 leaching trench using 4 H-20 0 and the Regulations of the Town of BARNSTABLE. AREA = 13,000:k SQ-FT- X9%W HICAP INFILTRATORS with 4# of 6. Provide an Acme Precast H-10, DISTRIBUTION BOX & 4. H-20 stone on sides & ends. HI-CAP INFILTRATORS OR EQUAL. 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. TH #2 8. Install gas baffle or equal on septic tank outlet tee end. 9. All existing inverts and site conditions shall be verified by contractor. 10. Existing leaching pit to be pumped & backfilled. X 969' 11. Provide 1 - 4" dia. SCH 40 PVC observation port to within 6" of grade. AJ HIGH CAPACITY INFILTRATOR . CHAMBER INFILTRATOR HIGH CAPACITY -CO 0 Os TRENCH DETAIL NOT M WALE MOUND FOR PROPER DRAINAGE� ESTABLISH VEGETATIVE COVER SOIL EVALUATION & PERK TESTS Date of Perc. Test: SEPTEMBER 30, 2005 61 MIN NON,-TRAFFIC AWEAS Test Performed By. GLEN E. HARRINGTON, R.S. NATIVE BACKFILL r12- H-10 LOADAREAS EXCAVATED BY . SCOTT FRANK, MASS CAPE CONSTRUCTION . ........... Test Hole Test Hole No, 1 No. 2 EESK IE5T DEPTH SOILS ELEV. DEPTH SOILS ELEV. PERK DEPTHI- C1 24 gala applied within 15 min. PROVIDE 4"DIA.SCH 40 PVC INSPECTION PORT USE PERK RATE <2 MPI FOR DESIGN PURPOSES TO WITHIN 6"OF GRAM NOT TO SCALE 0 0 A A .......... spa 5" sus BW BW ............ LOAMY SAIM LOAMY 1~ 2= 3D* iom 96.20 PERK TEST 161MEN, 10- INVERT PERK DEPTH- CI 24 gals applied within 15 min. C1 cl USE PERK RATE <2 MPI FOR DESIGN PURPOSES 751 4 I6 9,601 112r0 "AS (EFFECT IVE I -:M 11 F-M WAW LENGTH) LooE � LOM Inn! NO GROUNDWATER ENCOUNTERED NO GROUNDWATER ENCOUNTERED 101 EFF. iOOF PROPOSED SEPTIC SYSTEM UPGRADE DEPTH N PRVrM IN *NOTE: ALL PIPES ARE TO BE 4" DIA. SCHEDULE 40 P.V.C. 340 T co-4. SCOTT FRANK *NOTE: INSTALL GAS BAFFLE OR EQUAL ON SEPTIC TANK OUTLET TEE. NO SCALE 070 AT 10' min. from— house to septic tank s GIS1 GONCALVES, 74 WINDSHORE DRIVE tank covers must be A(/T fk\ Existing House 6" of finished grade Finished grade over systsm-2%, slope away NET '9\ BARNSTABLE (HYANNIS), MA 5 HOLE EXIS77 E DIST. BOX Existing Grade EIsv.-99.W* ------------------- - EXISTING 1000 G& port H-10 SEP710 TANK within 6* of fiVished grade within 61 a, finlelod grade 2*min. -washed *ton Max. GLEN E. HARRINGTON, R.S. PREPARED BY: S Q02' 0—Box cover must be do min. V-1/ar-1/e Provide l-4;" dlo- E:9 fu double _ff"mHievel for 2 DENOTES EXISTING S-.O1 Peastgne Ele =96.70' X 104.4e 9 LEDA ROSE LANE cel I a r AYARM-0 32' SPOT GRAM ffLo,* for 2' couixo—wasn" mon L 6.7' min. read.) FAX: 508-428-3862 c SEPTIC TANK land-QLv,—=W.20' —95— EXISTING CONTOUR MARSTONS MILLS, MA 02648 H-10 MIN. GAS BAFFLE OR 82 AL It Z 9 de"v- 37' DEEP TEST HOLE TEL: 508-428-3862 APPROX. LOCATION EXISTING WATER SERVICE V OF 3le-111:r STONE $ LEACH TRENCH c; V13gtt!2m of T.H. #2 elov.-88.70' 3le to 1 1 2: & I I SYSTEM PROFILE OF 3/r-11/2' STONE doubts—washed '1111 e--,N SCALE- 1 "=20' DRAWN BY: GEH OCT. 3, 2005 6 EXISTING LEACH PIT Not to Scale ( 0 ) TO BE PUMPED & REMOVED SHEET 1 OF 1 DATUM: ASSUMED FILE: FRANKWINDSHORE