Loading...
HomeMy WebLinkAbout0009 WOLLEY ROAD - Health 9 w& ley Road Hyannis . P A = 270 157 o � I 0 a r �� o s . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 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. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms the computer, r,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name 1161 rlb P.O.Box 763 Company Address Centerville Ma. 026+32 City/Town State Zip Code (508)477-8877 S14454 Telephone Number License Number B. Certification 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 4/7/2011 n9-1 Insp ctor's SignhTuFe Date The,system inspector shall submit a copy of this inspection report to the Approving Authority(Board U) 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. f I V v vl t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 4 " Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): 1 ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: , ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 1/z 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 ^M 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a'tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 every 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): 3 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 9 Wolley Rd.. Property Address Trinidad Alvarado Owner Owner's Name information is Y required for Hyannis Ma. 02601 4/7/2011 every page. City/Town 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 every page. City/Town 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) ❑ 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 ,M 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 every 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: 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. 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the leaching trench. Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 4" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 " Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name ' information is required for Hyannis Ma: 02601 4/7/2011 every page. City/Town 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 28" 011 Scum thickness Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 9 WolleY Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 every 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.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 every 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 No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage. 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: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 l WolleY Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-4'x54'x2' ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Stone was dry at time of inspection. 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 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page,1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size Zoom Out ifl J ?IJ In Ov ao h4 01 3 aka _ xil. 44 d V. 0 }' 14, w p� M fits 1{ 5al 2.0 F tF .r . tza„ - , Set Scale 1" = 20 Aerial Photos I MAP DISCLAIMER �_... (:n—rinhf 9MG_9Rin TnUin of Qn—efshlc NAA All rinhfe rocs—, http://66.203.95.236/arciriis/appgeoapp/map.aspx?propertyID=27,0157&mapparback=270157 4/7/2011 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for.Voluntary Assessments ;M 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 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 high ground water: Bottom of leaching 30' 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: 2006 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. 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 Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 every 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 a, Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 9 Wolley Rd. Property Address Trinidad Alvarado Owner Owner's Name information is required for Hyannis Ma. 02601 4/7/2011 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. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 026+32 City/Town State Zip Code (508)477-8877 S14454 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: a ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1/ t 4/7/2011 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. j t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 � f���Z n`�G'$s 'o 5� • z � ilk Custom M�p Lin g■®• . � F9 t D x 02�+ 9t R , it I i 3` £r '__ } 2c+-•�a�s..i>.::'.'.'a=": '�1�hv..V$ :�._s�i.ezzc Y-'.-...,^-'<-�• ? -�'h�.r`Pdn'.*�-�.,�4-w+��e=.-�>�`�e-w)y�.:-�... � .�e��,_`-�,� x t s 3 i - Cli '�. z a r S s a �► _ a - ,-x.+G.,.��r�w�F..._�<•�•- _ .rxaq`,..tY.�-�=`-:-:-�svy. � � _.�.,..-. Y�.,T4R+�:w -w.a,�.. .rv�'z��_,-��ww�s?x,a:. _.�.+o-`_ _ r cr S��-A. .��:-N -,..ve->s•e—-=wS,..z:�-.3-rh�,w-».- <>� -.,< .. i g# -.-. ;> >. �.--> _..�.ri,::..?-�.ems'--�-�- > 2 - i 4ce_4_.'4 � " t r�cy�:ce-.a� � � �.�r-w,•>x;.�.s ? Tia ��� g -.sexy'-u�n•.�s'+A--� _ � .:__...Ge_....- �-�.dZvr feu .,.. .-..f- .,...,Z � ... ».�...--.r-:��:.<$......,...r �F�L 3 oa '��#•"' _�------"���' —--=sue--.",ter--�.�.-�:9.,,:� - �; £ i rt z1 s i _; �• � 3 � I ¢ s -j3 ° 3 � 4 • • �i> z L e ... .-w>s..�'�..> c_�= -m:•—°sue-uc.->=�. -.:y::� o--fax-r._ - � �<:_-c-:,?::-:>a�.� � ._ >��..v-:�cc- 't_� i 7 _ r. _ �.L�ia+^rN;i. _ .. •4 ao3c�.>__ ' _.a•'�;,.: - .. 3- w �Y.. `cT+a��-'?Fs:'r.+;x�..-�L o..•--'�v- � +s!�.v - �e--of� E _ €�t191 O�'- 'ate i � �� zr€� € ���► � i q L e r f ,��_e�Aw--.�_ve-�:?-'--.•-r.�...-..-.x.F. .. = '�•�.c..�-.-.-p+-..�..c--�--1-+.�i�-�.---"e`- 3ac�.v :��.«.---;-- ,� _ ,-�=�.ea• � ter, �� f WIN +�.a<> E £ - - - �a...a•.,.s-m`em'w� �.�--�.-.>._ rom;.o.�T�. —'- � ; �"""-,.^'t',.�"' _ a "'f �""'- a I E '��"•z.£<3,4�� MEN ME F '- s s > i : i ' V:r ......................o..e*Fr>z-Y;:axaz.. ari>a: a:-x:t-x?...�' xxi.: ='Y-:�£*-'w..r- sn—< .e+atw,a•_.;5.,: xv$>._-.em-��...3:x-:,�- .E_>.--wr.,�:.se>z�->ryi�. '-"y'=.y;'a,._-c�.s. ,aac '>- < j .�x..a = ` � - F � � y Ey F1. oil if RICH Now „et:.�..; .->.�ra--,,.ms.m.� _ .�.isa.-a.e�.w.a � �,_;""�D.,:.-.� = .x ? e.-n»*�--. __ _ .,oa } >x�-��:._��.•->=il_ pi $ ,rv`�>- IR NOUN s s _� _� e IN <a._ } ,>..:.. arts ` -sue..§ to Y"- t _ �.aY,o-v- � s t > • w.YcR- t v-v-..a�?,c� 4 .�.:-:.., �-r >,.><w I i � i\ s 3 � t,y,,,.� t F T '-�• 3 S � a,.s.z ->'- � 3 .Y. .:� ,>.�-,.fin.:-.cF�.- .�_ �»£-�.� _ .-�tS:.�>:s..�;��.: s. _� ;s £ �..a.gin-t.>_€,.-.,� �.:�.,�• �i�' >r..�:; -' ,�-.u--.�.-.�:..Eay.�•.9. ,:..:,::y. =.:x�S;y-�:,:.` :-x.�...�-rates-.'.�F�^ �7.-�,e"�M»-££��s:.�;'a=>s,. -,..,�.�.'x,..,��.,-._.°.-��,aY'»...�"s ..a.,'�-a,.»rfm-�z�::c= ys....�- �^= F E v € mh'RjvJ«+^3.->(. .>,3>u.a_-,,. .,zX .o:> ,�-av-.�.�.>P:;,,,:.>-}, _-. >_, .. £ -3._ 3_ '•: 'z3 .�'� i f - .. -a.'czs-:ctx>�. ..ma+v>z'�w.-.+:4'-4vv >.d4u¢k3�'ac>.>.'��•Y-.z.�:z:ta.<_ir�x'Tw»-.--tazw?ti=a�=;�'-ti:,tF>:+�+Y:3Y.xa.`�',ascy(^z.:zora- g' �.,�ar ws�az`www-.�Y?+b<`:`.>' i ijr > a c s t r € ra >.,:.'. —#�Sat� cc�z�=:_ f�>r�-„g+ca�.�>- � F L-ra�s �a.��..�;>�`.a�--••� ` s�.x�:.ve-wvtz�iava FL MON 'ems I TOWN OF BARNSTABLE LOCATION 2 W u � It /Z C) SEWAGE # VLT LAGS n rl,• ASSESSOR'S MAP & LOT Z7v IS-7 INSTALLER'S NAME&PHONE NO. _W 1 4- 91' VUa-y SEPTIC TANK CAPACITY !,S-00 LEACHING FACILITY: (type) `X fV X �_ (size) NO.OF BEDROOMS 3 BUILDER OR OWNER - PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility NG Z 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 d �vo zAa o I TOWN OF BARNSTABLE LOCATION, 0 SEWAGE # VLLA>'iE �-( 11 Z ASSESSOR'S MAP & D8TALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) N0 0F BEDROOMS BUILDER OR OWNER 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 W NA r r6 O 4 r _� t No. 217 Fee v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pprication for Wgpogar 6pfstem Con5tructton hermit Application for a Permit to Construct( ) Repai Upgrade( ) Abandon( ) ❑ Complete SystenX Individual Components Location Address or Lot No:49 G:)0� pQ>7 Owner's Name,Address,and Tel.No. - - �S AL.v ra-e7a sx� —T2r nt�9�l:PS Assessor's Map/parcel 30 t' cJ SAME Installer's Name,Address,and Tel.No. P-L" Designer's Name,Address and Tel.No. CA-PC-LOL->G EtJT- Luc crju. �34C5, 1-I Z L46 SN--39 Type of Building: I Dwelling No.of Bedrooms _ Lot Size 0CD 1sq.ft. Garbage Grinder (/ K Other Type of Building �j 6 r2 No.of Persons + Showers(v) Cafeteria(✓) Other Fixtures LPro AT0�`� /c� ✓� if�k+ Avr�h�'1 Design Flow(min.required) ® gpd Design flow provided ,j 3 gpd Plan Date D Number of sheets Revision Date 1 Title < � Size of Septic Tank & rs-T 1.VL G cx-\ - Type of S.A.S. -TVT;,Nk+F S4 a X 4f'X 21 Description of Soil D\ Nature of Repairs or Alterations(Answer when applicable) (�\ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o Health. Signed Date Application Approved by Date roa Application Disapproved by: Date for the following reasons Permit No. Date Issued �/o No. � •G.V7 Fee r � � d j! THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS Appricatiowfor Thgpo.�al *ipgtem Cow9truction Permit r .� ,. Application for a Permit to Construct O Repair Upgrade O Abandon O O Complete SysteX Individual Components Location Address or Lot No.TI 4/0,tp Owner's Name,Address,and Tel.No. Assessors Map/Parcel 130 1 S} Installer's Name,'Address,and Tel.No. �� Designer's Name,Address and Tel.No. 0F+VtL0tDG EN LLC C► J. Svcs. H2S-4n 2A, ?)q-39 Type of Building: 1 Dwelling No.of Bedrooms Lot Size 500Isq.ft. Garbage Grinder (iJIA Other Type of Building �� �)0,P No.of Persons + Showers(V/') Cafeteria(✓) Other Fixtures Design Flow(min.required) ,�?J gpd Design flow provided gpd Plan Date 41 IF. I o (o Number of sheets � Revision Date —� Title .. y �1-�z� (`�US£2 SszD-�'1 C S S M o fi)Ca-O Ae i Size of Septic Tank ► 5L C,a\ . Type of S.A.S. _� -T' A* .Stl ��(`-1 X L1 Description'of Soil �� k P ( applicable) � 'D\CC_1 Nature of Repairs or Alterations Answer when a licable a: i fiw Date last inspected- Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ...tea ' Signed _ _ Date Application Approved by Date Application Disapproved by: Date for the following reasons 1 Permit No. c 0 Date Issued / 0 `THE COMMONWEALTH OF MASSACHUSETTSiy =\ - BARNSTABLE, MASSACHUSETTS l Certificate of Compliance � t .. . THIS IS TO CERTIFY,=that the,Ons �'etage Disposal System Constructed ( ) Repaired ( �UPgrdXed C y) Abandoned( )by I�� � l S�S LLC -` at !j I - has been constructed in accordance with the provisions�of'Title and the for Disposen ,System Construction Permit No. uY9 2/7 dated � /a \ Installer C4�11�� �ti Designer #bedrooms Approved design flow 33 gpd ` The issuance of this permit sha I not b construed as a guarantee that the system mill f n tiTnasli-Q.�d. Date � Inspector a..._-�....► —————————————————————— Fee ———No. r 7 THE COMMONWEALTH OF MASSACHUSETTS _ PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS D'h6 pogar 6pgMem Con!6tructiou Permit Permission is hereby granted to Construct ( Repair ( ) n Upgrade ( ) Abandon ( ) System located at ( and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided:Xonstruction must be completed within three years of the date of this permit. Date 6 l Approved by - i Town of Barnstable �ptME 1ph, Regulatory Services �O Thomas F. Geiler, Director ► anaxsrasi.E, ► MAS& Public Health Division 1639. ,erED�^p,�A Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Designer: Shay Environmental Services, Inc. Installer: Ct9�6e- Address: P.O. Box 627 Address: 4a East Falmouth, MA 02536 On J 1 Z-O(P "C- �-�. was issued a permit to install a (date) (installer) septic system at based on a design drawn by a dress) Shav Environmental Services, Inc. dated - (designer) VV i I 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. � 1�k OF Mq&Sq�r a CARMEN staller's 'gnature) E. `= SHAY No. 1181 o �S GIST P igner's Signature) (Affix Des> 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 TOWN OF BARNSTABLE V LOCATION 9 SEWAGE # -�7q VILLAGE 14 gen4yt S ' - ASSESSOR'S MAP & LOTgO INSTALLER'S NAME&PHONE NO. f2 O n.?nAZ 5C--ra h— 7 7 S--77 76 SEPTIC TANK CAPACITY ISO LEACHING FACILITY: (type) i�tL (size) NO.OF BEDROOMS Z -`--BUILDER OR OWNER PERMIT DATE: i_ ZT�� _COMPLIANCE DATE:�t 11-L Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 ,. a� \+��� �.e �� ' g- �� . a �, C3 .. � � � � � � � � �/ � ``' G .' I f l i ��y 7 No. < < v�7 + Fee $5 0 _/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _�/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[ppYication for Mtgool *pgtem Con!5truction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 9 Wolley Rd. , Hyannis, MA Estate of Scot Stanley Assessor's Map/Parcel � - Br' , �ad.ford. Sherman, Executor Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E . Robinson Septic Service P 0 Box 1089 , Centerville Type of Building: Dwelling No.of Bedrooms 2/3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. Nature of Repairs or Alterations(Answer when applicable) New Title-5 septic system consisting of a tank, D-box and 2 leach chambers with stone all aroun .. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by s B d of Health. Q Signed C9u'G -�' pp Date Application Approved by C Date Application Disapproved for the following reasons Permit No. Date Issued No. I' ' / / - fee-�— THE'COMMONWEALTH OF MASSACHUSETTS - Entered"in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for aigaal 6pelem Conttructfon Vermit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Ldcation AY'.p./P dress or Lot No. Owner's Name,Address and Tel.No. 9 Wley Rd. , Hyannis, MA Estate of Scot Stanley Assessor's el B_. ford. Sherman, Executor Installer's Name,Address,and Tel.No. `' Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089 , Centerville Type of Building: Dwelling No.of Bedrooms 2/3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title S e of Septic Tank Type of S.A.S. Description of.Soil Sand. Nature of Repairs or Alterations(Answer when applicable) New Title-5 septic system consisting of a tank, D-box and 2 leach chambers with stone all aroun . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b t 's Elgard of Health. 1 Signed p Date,/ ''oZ3^ Application Approved by tt f �/�. Date I Z—Z S j Application Disapproved for the following reasons Permit No. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS Stanley BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( ) Abandoned( ))by Wm. E . Robinson Septic Service at 9 Wolley R .. , Hyannis _h been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No ' ))� dated Installer Wm. E . Robinson S r. Designer � ��� � A ? The issuance of this,1 ert�nit hall not be construed as a guarantee that the sy, em 11 function as/design Date r n Inspector [ P-111 L� V I l' V.l f --f� ^--- ---------------------------- ----r-- No. ' / /7' FeeJ0 Z -'d_/�� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE., MASSACHUSETTS Stanley ' i5po5ar *pgtem Conotructton Vermit 20 � 3 t -7 Permission is hereby granted to Construct( _)Repair.( X)Upgrade( )Abandon( ) System located at 9 Wolley Rd.. , Hyannis 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 be completedwithin three years of the date of thi e t. Date: _ Z 3 / / Approved by /� 'X-� 116199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) T William E . Robinson,S,rltereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 9 W o 11 e�r R d . , Hyann i s, MA meets all'of the following criteria: The failed system is connect to a residential dwelling only. There are no commercial or business uses associated with the dwe tng. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands thin 100 feet of the proposed septic system There are no pn a[e wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no anances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maxim adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor methofl when applicable) If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 3' B) G.W. Elevation +the MAX. High G.W. Adjustment ._= ; 6 , 0 DIFFERENCE.BETWEEN A and B 3 t L SIGNED : lit) G ✓ DATE: 3—g [Sketch proposed plan of system on back]. q:health folder:cent s O � y n w 4�� E �, �� Q I - � � �,\ - � \ l r _,, r ^J COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRON�MENTAL.TR:OTECTION- � fi0W"EP- pEPT Ci TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: i. MAP I J Owner's Name: PSis . _jA,4C4 PARCEL LET Owner's Address: SC•,v.w Date of Inspection: t 2.' 1 S•GT3 Name of Inspector: (please printEftglas A r wry Company Name: Dwiglas A n Septic Inspections Mailing Address: R0 taw 145 t%W •i"� LA 602632 Telephone Number: .)08-42045734 CERTIFICATION STATEMENT 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 pursuan�to�Secfin 15.340 of Title 5(310 CMR 15.000). The system: s Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:p� e,-- Date: /2 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- Notes and Comments *"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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: fit! Owner's Name: Owner's Address:. !beg.,, f Date of Inspection:_I �L- l S - O Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys<Ve em Passes: V not found any information which indicates that any of the failure criteria described in 310 CNM 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: 145 f!^A P 5vs<rti cc rid a!S Ae i.V c> 6w%rail0.�j System Conditionally Passes: one or mo em components as described in the"Conditional Pass"section need to be ced or repaired.The system,upo on of the replacement or repair,as approved by the Board ealth,will pass. Answer yes,no or not determined(Y,N,ND)in the owing statements.If"not ermined"please explain. The septic tank is metal and over 20 years old*or the sep. hether metal or not)is structurally unsound,exhibits substantial infiltration or exfilhation or tank fail i ent. System will pass inspection if the existing tank is replaced with a complying septic tank as app by the Bo of Health. *A metal septic tank will pass inspection if it is struc sound,not leaking an Certificate of Compliance indicating that the tank is less than 20 years old is av ' ble. ND explain: Observation of sewage bac or break out or high static Rater level in the distribution box due to brok obstructed pipe(s)or due to a en,settled or uneven distribution box. System will pass inspection if(with approval of Board of H broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced 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 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: IA2, 1/--- i Owner's Name: r o C .Pl;j c. Owner's Address:_. S nni e Date of Inspection: 12 -( jr- Ln 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. em will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system i ctioning in a manner which will protect public health,safety and he_en44r;^.nment• _ Cesspool or privy is withm of a surfa _ Cesspool or privy is within 50 f ring vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the sys is functioning in a manner that protects the public health,safety and environment: _ the system has a se and soil absorption system(SAS)and the SA thin 100 feet of a surface water supply or tributary to ace water supply. _ The system has a septic tank and SAS and the S ne 1 of a public water supply. _ The system has a septic tank and S d the SAS is within 50 feet of a private ly well. The system has a septi and SAS and the SAS is less than 100 feet but 50 feet or more from a private;em7passes ply *.Method used to determine distance **This if the well water analysis,performed at a DEP certified laboratory,for coliform baceriaa and volatile organic compounds indicates that the well is free from pollution from that facility 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. er: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: el W.,�lI e y Z.3 v" JMic . Owner's Name•_ S M Owner's Address: Date of inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for aIl inspections: + Yes No _ ;--'Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ —�ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ ✓3fatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool quid depth in cesspool is less than 6"below invert or available volume is less than day flow — ✓Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ L/l(ny 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. _-w-An portion of a cesspool or privy is within 50 feet of a private water supply well. 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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 mast be attached to this form.] NO (Yes/No)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. La S m rge yste s. To onsidered a large system the system must serve a facility with a design flow of 10,000 5,000 gpd. You must' to either"yes"or"no"to each of the following: (The following apply to large systems in addition to the criteria abo yes. no — the system is within 0 feet of a surface water supply — _ the system is within 200 fee f a to a surface drinking water supply the system is located' trogen 'rive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a pub ' ater supply well If you have errxl"yes"to any question in Section a system is considered a significant threat,or answered "yes"in 'on D above the large system has failed.The er or operator of any large system considered a significant threat under Section E or failed under Section D s pgrade the system in accordance with 310 CMR Page 5 of I I OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: GJ oh--j R0 Nvw.,Ni< kAcA Owner: tN� Date of Inspection: j3 t S b 3 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes Noo Pumping information was provided by the owner,occupant,or Board of Health V 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? _ _-- Wesas 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: Yes o 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(3)(b)) 5 I Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Rd i Owner's Name: Owner's Address: r ,o Date of Inspection: 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): _ Number of current residents: Does residence have a garbage grinder(yes or no):40 Is laundry on a separate sewage system(yes or no):-ejo[if yes separate inspection required] Laundry system inspected(yes or no): t�b Seasonal use: (yes or no):At EP1 fac,'�Opp 7,00 t Water meter readings,if available(last 2 years usage(gpd)): 7 4r pp 2 Sump pump(yes or no):W Last date of occupancy:LQ(f eo k C MMERCIAL/INDUSTRIAL: Type lishment: Design flo sed on 310 CMR 15.203): Basis of design (seats/persons/sgft etc.): Grease trap present ry r no):_ Industrial waste holding nt(yes or no):- Non-sanitary waste di s ed t e Title 5 system(yes or no): Water meter rea ' s,if available: Last date of cupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: Was system pumped as part of the inspection(yes or no):_LSD If yes,volume pumped:_____gallons--How was quantity pumped determined? Reason for pumping: TYPP F 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: Sy�l-Prh *j S V CJ1 Pa 40,fo 9.wo Were sewage odors detected when arriving at the site(yes or no): lJD Page 7 of 11 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:.�t (�(�I�p�,, r) Owner's Name:. !stal"fiV Owner's Address: 5.n,,,, e Date of Inspection: B ING SEWER(locate on site plan) Depth be]low Materials of construction _ _ C_other(explain): Distance from private w p y we ction line: Comments tion of joints,venting,evi a eakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade. Q ly Material of construction: concrete_metal fiberglass polyethylene other(explain} If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: l S OCR q Cc1 Sludge depth: G Y Distance from top of sludge to bottom of outlet tee or baffle: *7S — Scum thickness:]6 t c, e Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): G E TRAP:_(locate on site plan) Depth belo de:_ Material of co ction:_concrete_metal fiberglass yethylene_other (explain): Dimensions: Scum thiclrness: Distance from top of scum t tle t tee or baffle: Distance from botto scum to botto outlet tee or baffle: Date of last g: Co on pumping recommendations,inlet an tlet tee or bade condition,structural integrity,liquid levels lated to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: et U-V1 Owner's Name: Sr,.�r�iv,c.o G Owner's Address: Date of Inspection: 12 - -0-:�i TIGHT or HOLDING TANK: (tank must be pumped at time of inspecti ocate on site plan) Dep�belowade: Material of construction: co metal fi s_polyethylene other(explain): Dimensions: Capacity- Design Flow: ally/day Alarm present(yes or n Alarm level: Alarm in working order(yes or no): Date of ing: Co nts(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LeYej 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.): I.e kear,.. or o\� �r•i car✓ CHAMBER:--(locate oY site plan) Pumps in working order(yes or no . - Alarms in working order(yes or no Comments(note co ump chamber,condition of pumps ces,etc.); Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: r$ tyn2lie , tZt� .--► ' NAG Owner's Name: a M n !v Owner's Address: Date of inspection: /2-/S" -6 3 SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type 1 hing pits,number: ✓leaching chambers,number:2 12 y 2 s X'L- 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.): . CES S: (cesspool must be pumped as part of inspection)(locat u-si an Number and confi Depth-top of liquid to inlet inv Depth of solids layer: Depth of scum layer: Dimensions of ces Materials o ction: In ' on of groundwater inflow(yes or no): mments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: to on site plan) Materials of construction: Dimensions: Depth of solids- CIO ote condition of soil,signs of hydraulic failure, onding,condition of vegetation,etc.): i Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: el TO Owner's Name:_ Sm1 co rK a o Ce ►�•N c- Owner's Address:_ SCE •C Date of Inspection: 12-- t S —b _ 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. �fvN Of, 000S `e 31 2S 3p!got O O ys'7 A Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: cr tc]r dw y IT2c) fvyrw"31% Owner's Name: cbc&Ad cnr.n Owner's Address: Date of Inspection: 12—t S^0'3 SITE EXAM Slope% t e V a l Surface water% 0ej Check cellar: 'Ut I Shallow wells N v Estimated depth to ground water 1�Cfeet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-1f checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _Accessed USGS database-explain: You must describe how you established the high ground water elevation: A'c) q,J r/ SJrsi(/ La a c ' CO'M-MON-WEALTH OF MASSACHL SETTS _ ExECUTIX''E OFFICE OF ENVIRONMENTAL AFFAIRS E DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE RI\TER STREET. BOSTON hLA0210t r61"i 292.550o TRUDY COaE Secretar. ARGEO PALL CELLtiCCI DAVID B STP.i-HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 9 W011ey Rd.. , Hyannis NarneofownerEstate of Scot_ Stanley Address of owner: Bradford Sherman Fan . ,Exec'. Date of Inspection: {- /,2��rb-� 551 John St . , New Bedford. Name of Inspector:(Please Print)Wm. E . Robinson Sr . I am s DEP approved systerq or inspect rsuent to Section 15.340 of Title 5(310 CMR 15.000) Company Name. Wm. E . Robinson Septic Service Marling Address: PO BOX 1089, Centerville . MA Telephone Number: �8 CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and -maintenance of on-site sewage disposal systems. The system: 4' Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails 99 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 thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS (70 � 00 MPS revi seCd #9/L/9 8 Page l of ll i• �.:ried on Recgcled Pane, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) "rap"Address: 9 W0 ey Rd.. , Hyannis �wr>er: Estate of Scot Stanley Date of Inspection: INSPECTION SUMMARY: Check&A B, C, of D: A. SYSTEM PASSES: I have not found an information which indicates that an of the failure i Y e conditions describe �n Y d i 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. CO MENTS: r » B. S TEM 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. Indicate y s, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if_the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. f Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed h, revised 9/2/98 Page 2oftt ► f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 Wo lle.y Rd.. , Hyan<3 owner: Estate of Scot .Stanley Date of Inspection: 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 the ublic health, safety and the environment. 1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 1 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well: The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revise: 5/2/98 " Page 3 of 11 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Property Address: 9 Wolle,y Rd.. , Hyannis Owner: Estate of Scot Stanley Date of Inspection: D. SYSTEM FAILS: You m t indicate either"Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this etermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LAR E SYSTEM FAILS: You mus indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office f the Department for further information. revised 9/2/98 Page 4ofII f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, - — PART B CHECKLIST Prop"Address: 9 Wolley Rd.. , Hyannis Dateoflns"�gte of Scot Stanley it_- Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes i No ✓/ _ Pumping information was provided by the owner, occupant, or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and-the system has been-receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of-breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. V _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: v _ Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / (15.302(3)(b)) _ The facility owner(and occupants,if different from owner) were provided with information on the proper maintenaar."f SubSurface Disposal Systems. revised .o/2/98 Page-s of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Irop"Address: 9 Wolley Rd.. , Hyannis Owner: Estate of Scot Stanley . Date of Inspection:/-/; d` FLOW CONDITIONS RESIDENTIAL: Design flow: 41,56 g.p,d./bedroom. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow Number of current residents: (� Garbage grinder(yes or no): /LO Laundry(separate system) (yes or no)r-0; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):/L 10 Water meter readings, if available (last two year's usage (gpd): _ 1 99,9-11292_50--250 gal. Sump Pump(yes or no): A- 1997-1998 51 , 000 gal Last date of occupancy: `7—i,1 COMMERCIAL/INDUSTRIAL: _-" Type f establishment: Desig flow: qpd ( Based on 15.203) Basis design flow Grease trap present: (yes or no)_ Indust at Waste Holding Tank present: (yes or no)_ Non-s,al waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last ate of occupancy: O ER:(Describe) La ate of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System plumped as part of inspection: (yes or no),4 S If yes, volume pumped: 910-6 gallons Reason for pumping: _j=�°/ j 75 TYPE OF YSTEM 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) PA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known) and source of information: �•/a=• � � L4 _ `�, � Sewage odors detected when arriving at the site: (yes or no)A&� V 17 revised c/2/9c Page 6(if 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) -ropertyAddress: 9 Wolle,y Rd.. , Hyannis owner-state of Scot Stanley Date of Inspection: ^� B ILDING SEWER: li o to on site plan) Dep below grade:_ Mat rial of construction:_cast iron_40 PVC_other(explain) Di ante from private water supply well or suction line Di eter Co ments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:. (locate on site plan) Depth below grader Material of construction: 1/concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) c. y 1 1 Dimensions: k Ca JC l Q Sludge depth: ® e I Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ 1 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: I `� Now dimensions were determined: 'omments: (recommendation for pumping, condi�tio lof inlet and outle tees or baffles, depth of liquid level in relation to outlet invert, structural inteq ty,� evidence of leakage, etc.) /t/ L:44 6 � v GR E SE TRAP:' (local on site plan) Depth b low grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensi ns: Scum th ckness: Distant from top of scum to top of outlet tee or baffle: Distant from bottom of scum to bottom of outlet tee or baffle: Date o last pumping: Co en, (rec mmendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evid nce of leakage, etc.) n revised 9/2/98 � Page 7ol11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) -�roperty Address:9 Wolley Rd.. , Hyannis Owner: Estate of Scot Stanley Date of Inspection: l`/.Z TI HT OR HOLDING TANK: (Tank must be pumped prior to,'or at time of, inspection) (loc a on site plan) Depth elow grade:_ Materia of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensi s: Capacity gallons Design fl w: gallons/day Alarm pr sent Alarm I el: Alarm in working order: Yes_ No_ Date o previous pumping: Com nts: Icon tion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: l/ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, a idence of solids carryover, evidence of leakage into or out of box, etc.) PU)te HAMBER:_ (lon site plan) Pu working order: (Yes or No) Alnworking order(Yes or No) Cots: (nndition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: 9 Wolley Rd.. , Hyannis Owner: Estate of Scot Stanley Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_L,/ (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits', number:_ leaching chambers,number:- leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condi of soil, signs of h draulic failure, levAof ponding, damp soil, condition of vegetation, etc.) t i CESSPOOLS:_ 1 (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert Depth of solids layer: )epth of scum layer: NIL Dimensions of cesspool: Materials of construction: Indication of groundwater_ inflow (cesspool must be pumped as part of inspection) Com nts: (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Mate ials of construction: Dimensions: Dep of solids: Co ments: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page vortl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Noperty Address:9 Wolle.y Rd.. , Hyannis -1-ner: Estate of Scot Stanley Jate of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I i nil revised 9;2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) rop"Address: 9 W011ey Rd.. , Hyannis °"Estate of Scot Stanley Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater °��Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) /Determined from local conditions V Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation.. (Must be completed) TO J � revised 9/2/96 Page 11of11 All WILET PFM FROM I1E *NOTE. ALL PIPES ARE TO BE 4' SCHEDULE 40 P.V.C. tIsttLEVE F ttox sNAu K tY CONCRETE COVER SET LEVEL FOR AT IE1�Sr 2 FT VENT PIPE (O Least 24 Inches taN) o f a V''� $ c h [hatise 10• min. from D-BOX Dover must Schedule 40 PVC w/Charcoal Odor Fliter �� { 13o1odS'OUTLET ° `' " a ;� LNEW Foundation to septic tank e M of ttnished p o� : 4 'hrRa tj TOF ELEV = 100.00 (Assumed) in Of A ""'� w +J � within B in. of finished pods s'� ou1LET 12• salT Grade over Septic Tank - 99. (Made over D-Box - 97.50 ish Grade - Gov 97.50 e• ';i`. • �` /N 's :•t5 S• 4' - SCH. 40 T t t.7S' S- 0.02 3 HOLE H-10 ,r orwr Top Of system ELEV. 94.00 '� a' g ,5• EXIST. s-oao or Greater BOX s_ a010-p.r foot , PLAN SECTION CROSS-SECTION DaST.PIPE ` ao 1,500 GALGREAS Psrllsetod P.vc -t/B'-t/r wauea slam UFs asgKo.l ` FROM rOUNDATmf 01 �' Ir Invert Elev.-93.50 J av „sd► SEPTIC TANK N ^ a n 5• n /4-tIi tN; ; 4 Bottom of Leach FacilityBev.- 91.50 c o N H-10 m ri , 3 HOLE H-10 DISTRIBUTION BOX ,0 / a 4 o CONCRETE FULL FlDUNdITION--� - rn 0 NOT TO SCALE o N o N 1 N Mohc AR boob sws to tr agp.a of.ed../PVC eaPa 8' HIaWOED ►w ysep�re201stiAREO� � SYSTEM PROFILE 6 Imalf 3/4-1 I/2' o iD : > Bottom of Test Hole 1 Oev-86.00 �«+� � «» o o Ta 0 LEACH TRENCH GENERAL NOTES Not to Scale i (1 TOTAL) LEACH TRENCHES CROSS-SECTION (2 TOTAL) 1. Contractor is responsible for Digsafe notification E: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE ��rwa. and protection of all underground utilities and pipes. NOT 2. The septic tank anc� distr ution box shall be set level on 6" of 3/4 -1 1p2 stone. 4 r of lA r-,/r 3. Backfill should be clean sand or gravel with no Mtea St" stones over 3" in size. ,,,, 4. This system is subject to inspection during installation TOWN OF BARNSTABLE: P-11290 VARIANCE REQUESTED: by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance 1. REQUEST A VARIANCE TO REDUCE SEPARATION FROM AN SAS TO A FOUNDATION air-�� with Title V of the Massachusetts state code, the approved plan PERCOLATION TEST FROM 20 FEET to 15'. A 40 M1 Rubber Liner Has Been Provided r Forlealr P.VA*0 and Local Regulations. NOT TO SCALE 6. If, during installation the contractor encounters any Date of Percolation Test: MAY 10, 2006 2. REQUEST A VARIANCE TO INSTALL SAS MORE THAN 3 FEET BELOW GRADE. soil conditions or site conditions that are different Test Performed By. CARMEN E. SHAY, R.S., C.S.E. from those shown on the soil log or in our design Results Witnessed By. DAVID STANTON ( BARNSTABLE B.O.H.) A VENT HAS BEEN PROVIDED. NOTE: SHED MAY NEED TO BE MOVED TO INSTALL SAS installation must haft do immediate notification be EXCAVATOR: Shay Environmental Services, Inc. made to Carmen E. Shay - Environmental Services, Inc. Percolation Rate: Less Than 2 MPI ® 36" TEST HOLE #2 7. No vehicle or heavy machinery shall drive over the Test Hole #1 BY HAND AUGER on APRIL 17, 2006 by CES. ELEV.- 97.00 septic system unless noted as H-20 septic components. 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. SHED 75.00' 97r 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Test Hole Test Hole 97 1 10. All solid piping, tees do fittings shall be 4" diameter No. 1 No, 2 0.5 Schedule 40 NSF PVC pipes with water tight joints. DEPTH SOILS ELEV. DEPTH SOILS ELEV. 4" PVC 11. Municipal Water is Connected to ALL OF The Residence and Abutting 0 Gravel & 98.50 0 Loa97.00 0. 4, D-Box Properties Within 150 Feet. oensewade Sanndy ----------1 _____ _ THE PROPERTY LINES ARE APPROXIMATE AND 10 TR 3/2 to rR 3/2 kb ' COMPILED FROM THE SURVEY PLAN GENERATED BY O 2 PATIO i--- o SWEETSER of YARMOUTH. MA ENTITLED oamy Loamy O O PLAN OF LAND IN HYANNIS. MA" PLAN BOOK 226 PAGE 151 Sand Sand w w DATED DATED JANUARY 2, 1969 L AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN to TR 21 to TR see B•-34' Be 95.67 6•-32" By 94.33 ir"STI.�VG I ff SHOULD BE USED FOR NO PURPOSE OTHER THAN Medtum �m 98 THE SEPTIC SYSTEM INSTALLATION. Sand 98 2 s r$/s zs T e/b HOUSE EXISTING SAS TO BE PUMPED OUT AND FILLED IN PLACE 34'-132" C, 87•50 3r-132" C, 86.00 40 POLYETHYLENE LINER FROM ELEV. #a 94.00 to 90.00 AND TO EXTEND NOTE; ANY STRIPPED OUT SOIL CONTAINING LEACHATE - 10 FEET BEYOND EACH END OF THE BULKHEAD FROM THE EXISTING SAS TO BE DISPOSED ----- OF AS PER BOARD OF HEALTH SPECIFICATIONS. I j - EXIST. I I NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY I l L 1500 GALLON I l TEST HOLE #1 ASPHALT I SEPTIC TANK i I ELEV.= 98.50 ASSESSORS MAP 270, PARCEL 157 1 DRnrEWAY l -1 _ L N 99 l I 99 FAILED I I Perc #1 " �, PROJECT BENCH MARK I 'J_�----I"- I GRAB- Depth to Perc: 36 to 54 TOP OF FOUNDATION I i :DRIVEWAY I 104X1 DENOTES PROPOSED Perc Rate-- Less Than 2 MPI ELEV. = 100.00 (Assumed) *E - I SPOT GRADE Groundwater Not Observed J I LOT #9 l = DENOTES EXISTING No Observed ESHWT I I I I I x 104.46 SPOT GRADE ADJUSTED H2O Elev. = None 175.00 I 7,500 Square Feet Pic PL PROPERTY LINE 9iS PROPOSED CONTOUR ----- -97 EXISTING CONTOUR TYOLLE Y ROAD � TYPICAL 1500 GALLON SEPTIC TANK DEEP TEST HOLE & (40 FOOT RIGHT OF WAY) PERCOLATION TEST LOCATION NOT TO SCALE .--+ 6 FOOT STOCKADE FENCE 33 dM. ACCESS,,kola (H-10 LOADING) - Kitchen Bath Bedroom LOT P LAN Dining P OF PROPOSED SEPTIC SYSTEM UPGRADE T COVERS F THE SEDISTRIBPTIC c��T PREPARED FOR : -,!l ��z,,,'T.y, SHALL BE RAISED To wITHN 6" OF „� GRADE. Bedroom Living Room Bedroom ALVARAD 0 TR I N I DAD STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITS GAS BAFFLES OR EQUALS AT PLAN VIEW ON ALL OUTLET TEE ENDS 3_24•IMMOVABLE Cam 9 W O L L EY ROAD I 3 BR HOUSE FLOOR SCHEMATIC HYAN N I S, MA „� B-mkLF rr,m�«to auset r • r r "� Design Calculations ,r ilia-fwal >r 01"'�' �� o ASS PREPARED BY: s_r I 's_r Number of Bedrooms:3 Equivalent to 330 Gol./Day (330 Gal./Day Min. per Title V) Garbage Grinder. No A N Gcn CARMEN E. SH�1 Y § ...+. t qw depth Leaching Capacity Proposed: 330 Gol./Day Minimum (Min. Per Title V) m . Septic Tank : - 2 x 330 Gal./bay a 660 USE EXISTING 1,500 GAL. Septic Tank 0 20 40 5 ENVIRONMENTAL SERVICES, INC. •. �;�. i --:j�•-i _ ._.:f SOIL ABSORPTION AREA: Using percolation rate of Q min.�nch N . 11 ta'-ar a-r - 627 Proposed Leaching Trench Dimensions: 1 TRENCH -4' Wide by 54' Long by 2' Depth . .p p P.O. BOX OU MA 02536 CROSS SECTION END-SECTION Bottom Area: 0.74 gal/sq. ft. x 216 sq. ft. = 159.84 gallons s TRRa EAST FAL Sidewall Area: 0.74 gal./sq. ft. x. 232 sq. ft. = 171.68 gallons SCALE: 1"=20' gNrrAR�P TEL/FAX 508-5308-539-7966 Providing: 331.52 gallons SCALE: 1"=20' DRAWN BY: CES DATE: MAY 10, 2006 Use: 1 TRENCH - 541 by 4'W x 2'D PROJECT#SD901 FILENAME: SD901 PP.DWG SHEET 1 OF 1