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HomeMy WebLinkAbout0023 WOODLAND AVENUE - Health 23 WOODLAND AVENUE,HYANNIS A= 269 054 f l �i i I! I i i TOWN OF BARNSTABLE LOCATION ®�3 SEWAGE # VILLAG� ASSESSOR'S MAP & LOTAws, ��'7" NSTA=R'S NAME&PHONE NO. ��roo-es SEPTIC TANK CAPACITY E/2-1 L Zti S/°f C�Oa` LEACHING FACILITY: (type) (size) NO.OF BEDROOMS fn —7--- `-:BUyILDER OR OWNER '��yL ��IfIl A' PERMTTDATE: COMPLIANCE DATE: i 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 '1-=N �. � O �F � o ® o � � 4� a � o �, r'� r -" Commonwealth of Massachusetts a?�9-b Title 5 Official Inspection Form r,1 Igo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � (ri 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza l r, Owner Owner's Nat information is Hyannis MA 02601 08-26-2019 required for 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:When A. Inspector Information filling out forms on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road � Company Address Teaticket Ma. 02536 City/Town State Zip Code MIR 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 08-27-2019 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �n ►p Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis MA 02601 08-26-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 3 bedroom home has a 4 bedroom septic system. The system has a H-10 1500 gallon septic tank and a D-Box feeding two 3 x 30 leaching trenches. At the time of the inspection there were no failure criteria found the septic tank was pumped as part of the inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form '? 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis MA 02601 08-26-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static.water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis MA 02601 08-26-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis MA 02601 08-26-2019' - page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ,tip Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis MA 02601 08-26-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two.week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis MA 02601 08-26-2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 plus GPD Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 23 Woodland Ave V� Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis MA 02601 08-26-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: inspector Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons gallons How was quantity pumped determined? drivers est. Reason for pumping: maint. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis MA 02601 08-26-2019 - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 01-22-2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 15" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): water was flushed during the inspection and it came freely. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts ,� Title 5 Official Inspection Form II; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis MA 02601 08-26-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 8"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: standard H-10 1500 gallon Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? sludge judge 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 the time of the inspection the liquid level was at working level and the tees were in place. Note there is a filter installed in the discharge pipe. I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts ,�,p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Woodland Ave u� Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis MA 02601 08-26-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u� 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis annis MA 02601 08-26-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage. Note there are flow adjuster installed in the d-box. t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 I Commonwealth of Massachusetts _. Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V!% 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis MA 02601 08-26-2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (2) 3 x 30 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ,�,p Title 5 Official Inspection Form ii; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is Hyannis MA 02601 08-26-2019 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there were no visible failure criteria found 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis MA 02601 08-26-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic.failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �n p Title 5 Official Inspection Form 11I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v !% 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is Hyannis MA 02601 08-26-2019 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Derr�4- 4j- b�,o"� �- chj t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Assessing As-Built Cards https:Htownofbamstable.us/Departments/Assessing/Property_Valu... TOWN OFBARNSTABLE LOCATION J 3 o3-4 \a,J Pti. SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL 40-SY INSTALLER'S NAME&PHONE NO. Cae �S)\d¢ � lerertx VU qu28 SEPTIC TANK CAPACITY I:0 o it to LEACHINGFACILTfY:(type) 11 \k,Ctp (size)(a) 3x343 Sko44S) NO.OF BEDROOMS- y OWNER' 6aca, C iu t �o M. dot PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom bf Leaching Facility u 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 Of any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY V c. `t. 5- A 0 t z C y 13 • Ptl 17.° 3 �L. 10•v b Ri st•° a� IS' 31 t9 DS 9b-s 13Z a3.a 33 �g.4 1 of 1 8/26/2019,5:44 PM Commonwealth of Massachusetts Title 5 Official Inspection Form iI; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Woodland Ave u Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is H annis MA 02601 08-26-2019 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 11 plus feet feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date 2009 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: permit on file with the health dept. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 23 Woodland Ave Property Address Kenneth Sr& Monica Frenza Owner Owner's Name information is required for every Hyannis MA 02601 08-26-2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included y � No 1472 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / ��,�► �M 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is Hyannis MA 02668 April 16, 2014 required for every y p page. Cityrrown 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 on the computer, use only the tab 1. Inspector: J key to move your cursor-do not David B. Mason use the return key. Name of Inspector David B. Mason � Company Name 4 Glacier Path Company Address too East Sandwich MA 02537 Cityrrown State Zip Code 508-367-1617 S1287 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 t6 section 1;kM Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ FaiIt '' rY -r— ❑ Needs Further Evaluation by the Local Approving AuthorityW a April 18, 2014 NO Co Inspecto 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 ofA10,000 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. ****Thin report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:S bs 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 23 Woodland Ave, Hyannis . Property Address Margo Valentine Owner Owner's Name information is April Hyannis MA 02668 A 18 required for every y p � , 2014 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: ® 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: Inspection identifies the condition of the system on April 18, 2014 at 2 PM and represents the condition only for that date and time and does not represent the continued operation of the system in the future. 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. El Y. ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is Hyannis MA 02668 Aril 18 2014 required for every y p page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of 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-3/13 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 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is Hyannis MA 02668 required for every Y April 18, 2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. . ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 1/2 day flow t5ins-3/13 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 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is Hyannis MA 02668 required for every y April 18, 2014 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. El ® 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 El ❑ 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 If you have answered "yes to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. - t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is April Hyannis MA 02668 18 required for every y p � ,2014 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? ® 0 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. ® 0 Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15..302(5)] D. System-Information Residential Flow Conditions: - Number of bedrooms (design): ' 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 god x#of bedrooms): 440 t5ins•3113 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 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is Hyannis MA 02668 April 18, 2014 required for every _ Y p page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents:' 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information,in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? . . ❑ Yes ® No Water meter readings, if available last 2 ears usage Yes 9 ( Y 9 (gpd))� Detail: 2013; 57,000 gallons and 2012; 64,000 gallons Sump pump? ❑ Yes E 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: t5ins•3113 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 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is Hyannis MA 02668 April required for every Y pil 18, 2014 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: Board of Health Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons i How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system El Single cesspool El Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A'system by system operator under contract Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is April Hyannis MA 02668 A 18 required for every Y p ' , 2014 page. CityTTown State Zip Code. Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: January 22, 2009 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.): Obwervable conponents appear in adequate condition Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass' ` ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Typical 1500 gallon Sludge depth: 611 t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is Hyannis MA 02668 April 18 required for every y p �il , 2014 page. Citylrown 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 38" 5„ Scum thickness Distance from top of scum to top of outlet tee or baffle 2" Distance from bottom of scum to bottom of outlet tee or baffle 101, 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.): Effluent level with outlet invert. Obwervable portions of the tank appear in adequate condition. Pumping tank required. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is April Hyannis MA 02668 A 18 required for every Y p � , 2014 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: l ❑ concrete ❑ metal ❑ fiberglass '❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in'working order: ❑ Yes ❑ No Date of last'pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is Hyannis MA 02668 required for every y April 18, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information(cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level with outlet invert Comments'(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No evidence of solid carryover. Pump Chamber(locate on site plan): : " Pumps in working order: V ❑ Yes ❑ No* Alarms in working order: .. ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS).(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is April 18, 2014 Hyannis MA 02668 A required for every Y p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: El leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ , , leaching fields number, dimensions: El overflow cesspool number: ® innovative/alternative system ~y Type/name of technology: Hi Cap Bio Diffusors; 2 rows-30'lon Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2-500 gallon chambers with out signs of hydraulic failure at time of inspection. No damp soil 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is Hyannis MA 02668 required for every Y April 18, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on Site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of pond ing, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is Hyannis MA 02668 April 18 required for every y p , 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately . t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is Hyannis MA 02668 Aril 18, 2014 required for every y p page. City/Town State Zip Code Date of Inspection D. System Information .(cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar _ y ® Shallow wells ` Estimated depth to high ground water: 20 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: January 1, 2009 Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Ground water contour map Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high'ground water elevation: Existing soil logs on file with Board of Health Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Woodland Ave, Hyannis Property Address Margo Valentine Owner Owner's Name information is Hyannis `MA 02668 required for every Y April 18, 2014 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION 3 v3.4 and h+. _,SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL _40-S-Y INSTALLER'S NAME&PHONE NO. _Cape_ jNJ r? Div Y28 rfu2g SEPTIC TANK CAPACITY I 00 it I0 LEACHING FACILITY,(type) I Z k.Can I�it�b r(` (size)!a� 3 x 3 U SFsn2�e1) NO.OF BEDROOMS y OWNER' r~ C iU t 3, PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 1vo, 1 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) pe FURNISHED BY • le- C_ a».oa j�.. L0.0 LS LV:B R3 Si.o n� lS,b 3t tq.o DS �ba t3z a3.a . 63 a9•0 http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=269054&seq=1 4/15/2014 TOWN OF BARNSTABLE LOCATION J 3 W-0 \-ew) Nw, SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL JO —SY INSTALLER'S NAME&PHONE NO. C'"e w\J'Q &r e rrIDI t,.e SEPTIC TANK CAPACITY I 5-0 0 if /0 LEACHING FACILITY:(type) 1 Z 1},CQp I�jw'1),�=(� (size)o 3 x 3 U S I- Qn SJ NO.OF BEDROOMS y OWNER' �i-��° C 6 O e� J M•��� PERMIT DATE: llql6g COMPLIANCE DATE: Separation Distance.Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility u 1 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ^D `j o J c. N .G. �^` No. Fee THE COMMONWEALTH OF MASSACHUS` ,TS. Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for Bisposal Opstem Construction 30Ermit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.2 3 tj fla4 1 Qna q4v t Owner's Name,Address,and Tel.No. b i 1 v%ftCw 6 1LL•%o%.) Assessor's Map/Parcel Lyra•.+%?j2 Grq S Installer's Name,Address,and Tel.No.G,gq��,,�I 440 tt Designer's Name,Address,and Tel.No. SOTS `{2ft LIOZ!Z �P. b; a.•X S'0 8- Z'1 -03-�-7 �B Sy Type of Building: Dwelling No.of Bedrooms 3 Lot Size �'�1'b sq.ft. Garbage Grinder( ) Other Type of Building ��h.�,.` 1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3?!U gpd Design flow provided 3 (o . 3 gpd Plan Date I. (a - 2 0 04 Number of sheets Revision Date Title 23 t.)Sod >" Size of Septic Tank I tip Type of S.A.S. Description of Soil 02 X Nature of Repairs or Alterations(Answer when applicable) A'%AjA L_ (A Date last inspected: 2 Rai 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 b his Board of Health. i e ' m Date Oo Application Approved by Date Application Disapproved by Date for the following reasons WVYr Permit No. Date Issued M .}-.�_.. ....-......n`+T"w.'Nrw»i`.dw.`�+,%.t+.',,'K"AQ�+-Y,,.].:-t�tae�L�i,^r.Jlrr"f^'iY�}.� .. �...... , ......� -. +." c..^Wa h... s��.-.r4.. 1y14Fr.1,...r.y. -•,�.. ... ,. n..w, r, ry '.rm: Fee ! /�/=/— ,4 THE COMMONWEALTH OF MASSACHUS `r TS"f Entered in computer: Yes PUBLIC HEALTH'DIVISION -TOWN OF BARNSTABL�'';�MASSACHUSETTS - Npfication for ]Disposal 6pstem Construction" permit ' Application for a Permit to Construct( ) Repair(X) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. a rc� Owner's Name,Address,and Tel.No. t 1 v" Assessor's Map/Parcel � � '2 C,.,-, >M Installer's Name,Address,and Tel.No.6' ,p_ �� .�� Designer's Name,Address,and Tel.No. ` y/ x/ (' ^ "'C G• ...1 V� 1 (-V 1 Y}A7S 7 M- �G 5 �`I L: e2✓7�-�.r. ��crL� Ce tom- �. 3 OZS . �.� Type of Building: Dwelling No.of Bedrooms Lot Size j x- l ( 1 sq.ft. Garbage Grinder( ) Other Type of Building _�; 44— 4 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow min.required) u L gp g ( q ) gpd Design flow provided 3 J d / Ian Date o Q a Number of sheets Revision Date Title '1-: Li oc�, k Size of Septic Tank 1y Type of S.A.S. Description;ofSoil t` � 0_ V., �^ ' Nature of Repairs orAlierations(Answer when applicable) aX (2� �` ✓-e,.1c�- Date last inspected: oV? 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 b%thnis Board of Health. ed_ A a ,-� Date Ov Application Approved by ® � �' %/ Date Application Disapproved by Date for the following reasons Permit No. ( .� Date Issued / v eu 1 ------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Q ) Upgraded( ) Abandoned( )by /��,,) �� l ��, t L_\ (-- at has been co d in��ayycco dance with the provisions of Title 5 and the for Disposal System Construction Permit Nonstruct dated Installer ( A, (91,_ F ) � t��!�f ✓,`�t� Designer L C ►'1 #bedrooms Approved:de/sigr flow / ,_ ,6 ® gpd The issuance of this permit ssp�all of bdconstrued as a guarantee that the system l ct�on as des/irgne/d� + U' Date / ! Inspector e�i �7 /��'.� 1 � J % 1 No. Fee_-- � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposai 6pstem Construction permit Permission is hereby granted to Construct( ) Repair(4) Upgrade( ) Abandon( ) System located at '-3 Goo o A 1 A h AQ 4k,Q { and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction.mussttt�be completed within three years of the date of this permit. l / Date / �(/ Approved by Town of tfarnstawe,-•- - Opt.E . Regulatory Services BAItNSTABLE, Thomas F. Geiler, Director y_ MASS. i639. `�� Public Health Division AlfD N1°'� Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: L2 2,11)1 Designer: TC /)G�/�L�z- /J�� ^ .. _. Installer: Ci ty)igi b-J7 ,4gSJ7 5 Address: Sy C4 Zs��i� GE/wt?�/ Address: Lf 56 7 fihft ,,r// 2674V 024` 3 Z On ;' was issued a permit to install a (date) (installer) septic system at J01A-41) based on a design drawn by (address) Z—C �/N�'�IZ��J(�, /6LC dated (� (designer) 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: �7H OF _ JOHN L. �a staller's Signature) U CHURCHlLL JR. IVIL 416 7 ZASE signer's Signature) ( fix 1 s Stamp Here) P 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 P# Department of Regulatory Services BARNOMM Public Health Division Date 200 Main Street,Hyannis MA 02601 �0 tom" Date Scheduled /CT 6 Time © Fee Pd. ! O Soil Suitability Assessment for Sewage Disposal Performed By: MICHJJEt- t?1MZ arEA_ EtT L'5E Witnessed By:_! 0wpu0 `7l eswit Ats P.S. LOCATION§f GENERAL INFORMATION ) Location Address �j� n Owner's Named Address 23 uoeo6104 WC Assessor's Map/Parcel: 01 L S / Engineer's Name 'SC, ehbCnek-f111•rJ t 11 iC NEW CONSTRUCTION REPAIR Telephone# 50 0.-2.7S-O S T7 Land Use Z�'-1­E• VA-14.v Slopes 2'(` Surface Stones Distances from: Open Water Body 1150 ft Possible Wet Area �150 ft Drinking Water Well ft Drainage Way t0 ft Property Line >1Q ft Other — ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) ti `jEE AITFKAWEO t?LAN ^' durw� Depth to Bedrock > 20` ►'�•(0.5• Parent material(geologic) p Depth to Groundwater. Standing Water in Hole: lacy 13-c•S• Weeping from Pit Face 13o 13' Estimated Seasonal High Groundwater 130 �•�•,5. DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Dtftu 66WAuAt00r1 Depth Observed standing in obs.hole: "�� .f3(o3 __in, Depth to soil mottles: D t3o" BfnS. In, Depth to weeping from side of obs.hole: 130- Stay in, Groundwater Adjustment ft. Index Well# Reading Date: — Index Well level Adj,faetor Adj.Oroundwater Level,,, PERCOLATION VEST bete 12 si d Time to,, 0 AN► Observation Hole# t Time at 4" .. Depth of Perc 32-50 ^` Time at 6 ^ Stan Pre-soak Time @ ao:oy AM Time(V-61 — End Pre-soak t0:'S Am Rate MinJlnch 2 Site Suitability Assessment: Site Passed '� Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# ' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,%Gravel) y �ti- A LoAmn 5gn40 Ib"d 91, 1,i" 3z" g t-4AM4 5arra to'iQ sir W e-t Cvaasrr 5AMo t•51 ok. $p-13p C-2 41EO UM SANo 7,rDi °�U a o(>SE ' to-Zeto C'"U"' . SamE CoBgt.CS , DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) A 1MIIAI .SAID to 3 t 14--3z- 6 LOAMY SAND to YQ 5I� 32"-bo" C-1 CoA SAr-0 MEOlUrn S NO . `I ° dG05>✓ rc0-so`10 C-194UFA • SomTs Cpeet.e� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (M ) g unsell Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munseli) Mottling (Structure,Stones,Boulders. consistency. I Flood Insurance Rate May: Above 500 year flood boundary No— Yes ___ Within 500 year boundary No✓ Yes Within 100 year flood boundary No '� Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? yEg _— If not,what is the depth of naturally occurring pervious material? Certification I certify that on ic'`27'9q (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise a experience described in 310 CMR 15.017. Signature' ///0//1-V f Date QASEPTIMERCFORKDOC Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 23 Woodland Ave. Property Address Bill McWilliams Owner Owner's Name information is required for Hyannis Ma. 02601 12/16/2008 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. Please see completeness checklist at the end of the form. Important: A. General Information When fillingfilling out Z�7 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 - r� P.O.Box 763 Company Address Centerville Ma. 02632 rerwn City/Town State Zip Code (508)428-4028 S 14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and thaithe - information reported below is true, accurate and complete as of the time of the inspection. Thginspection was performed based on my training and experience in the proper function and mainlenance-of on side { sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15;40 of.� Title 5(310 CMR 15.000).The system: ' ❑ Passes ❑ Conditionally Passes ® Fails& t ❑ Needs Further Evaluation by the Local Approving Authority . r r— rn 12/16/2008 lnspec'fo siglhauKe 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. I Z/ t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 2 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 23 Woodland Ave. Property Address Bill McWilliams Owner Owner's Name information is required for Hyannis Ma. 02601 12/16/2008 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: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in.the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2 f Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 23 Woodland Ave. Property Address Bill McWilliams Owner Owner's Name information is required for Hyannis Ma. 02601 12/16/2008 every 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 FIND (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 1s 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 3 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 23 Woodland Ave. Property Address Bill McWilliams Owner Owner's Name information is required for Hyannis Ma. 02601 12/16/2008 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 23 Woodland Ave. Property Address. Bill McWilliams Owner Owner's Name information is required for Hyannis Ma. 02601 - 12/16/2008 every 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 ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ 1:1 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Woodland Ave. Property Address Bill McWilliams Owner Owner's Name information is required for Hyannis Ma. 02601 12/16/2008 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? Y P ❑ ® 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. ® 0 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 23 Woodland Ave. Property Address Bill McWilliams Owner Owner's Name information is required for Hyannis Ma. 02601 12/16/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 6'x8' main cesspool and a 1000 gallon leaching pit. 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 2007-08:73,000 9 ( Y 9 (gpd)): Detail: 100 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: 8/2008 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Woodland Ave. Property Address Bill McWilliams Owner Owner's Name information is required for Hyannis Ma. 02601 12/16/2008 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 um in : p p 9 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 23 Woodland Ave. M Property Address Bill McWilliams Owner Owner's Name information is required for Hyannis Ma. 02601 12/16/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: New leaching pit installed in 1983 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 16" Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ® other(explain): orangeburg Distance from private water supply well or suction line: feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal, ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions:. Sludge depth: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Woodland Ave. Property Address Bill McWilliams Owner Owner's Name information is required for Hyannis Ma. 02601 12/16/2008 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 Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Woodland Ave. Property Address Bill McWilliams Owner Owner's Name information is required for Hyannis Ma. 02601 12/16/2008 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 23 Woodland Ave. Property Address Bill McWilliams Owner Owner's Name information is required for Hyannis Ma. 02601 12/16/2008 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any, evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments q , °wM 23 Woodland Ave. Property Address Bill McWilliams Owner Owner's Name information is Hyannis Ma. 02601 12/16/2008 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gl. ❑ leaching chambers number: ❑ 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.): Sandy soil.Pit was dry at time of inspection.Stain line observed up to top of pit.Sides of pit has heavy solids in holes.Pit is in hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 main and LP overflow Depth—top of liquid to inlet invert 7' Depth of solids layer Depth of scum layer 6'x8' Dimensions of cesspool Materials of construction Concrete block Indication of groundwater inflow ❑ Yes ® No t5ins•09/08' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Woodland Ave. Property Address P Y Bill McWilliams Owner Owner's Name information is Hyannis Ma. 02601 12/16/2008 required for Y 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.): Mian cesspool was dry at time of inspection.Heavy solids and caked grease observed on bottom of cesspool. 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.): i t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14 f Map Page 1 of 2 Town of Barnstable Geographic Information. System 4 Parcel Viewer Custom Map Abutters Map Size ® zoom Out J 11 'J I jIn 1d IC K X 1 'k 1 - 1 Y 1 • . L---—--——---——--- --—-------————-— -—-——_ 4 � F' se • 1 .. L R . L ''Y 1 t a . I L 1 L T 1 I I t� Lp • L _ -.•r- a •.I - f l3s` I r F' II �'£ x �� IIII fly • L; I , 1 1 LL - ---. - ------- - --- 1---- `- 0 _- -2'0-Feet "L 1 I { Set Scale 1" _ 20 I Aerial Photos I MAP DISCLAIMER r° ('n—rinhf 0AN;-')OOA T—Aln of Rornefohlo RA All rinhfe rocm—i b.ttp://www.tovm..ba.m' stab]en a.us/arcims/appgeoapp/map.aspx?propertyID=269054&ma... 12/18/2008 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 23 Woodland Ave. M Property Address Bill McWilliams Owner Owner's Name information is Hyannis J Ma. 02601 12/16/2008 required for y 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 LP 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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) f _ ® Checked with local Board of Health-explain: As-Built Card ❑ 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 92-000-01 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Woodland Ave. 'M Property Address Bill McWilliams Owner Owner's Name information is required for Hyannis Ma. 02601 12/16/2008 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ,ac ,�,, :wr�•.,,,,. ,.;:- cn*.usaa-.a!use+txmm�tw�?�.�2'"+'r.Y�mawArrrt�:,dr.s.,. _ ,m+-*:x•.••ttm..'.PaaR^nr•.•srvwv.,.*+ye,!. >,T++rimrcm,mrvxe,.lnrsumrtsmurwsr�7na'.nwsamrscawsM�lat<aen .. .. .. aHcv+F•'.°rf�,' Commonwealth .of Massachusetts �t Executive of Environmental AffairsDEP Department of x 19� f . �.' �41y Environmental Protection 4°j!� w.'" z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION 4t Property Address: A3 wc�lxtt-.a pot<_ Address of Owner: „;�� (if different) �.►,x ''���' Date of Inspection: k Name of Inspector Company Name, Address and Telephone number: `- 4 CERTIFICATION STATEMENT } ` certify that.I have personally inspected the sewage"disposal system atthis address and that the information reported below is true, accurate and;completeas of:the time{of inspection The',"inspection was performed based on my training"and experience in the P P r nA , fi x j. RR> tk4 bf kd k function.and maintenance of on site sewage dis orals stems W,'8 s stem s proper g P y, ,.. s y, S�kr t i r Passes , ? Conditional) Passes Needs further evaluation by,the local Approving Authority Fails s 'v 4 Inspector s Signatur I Date:;-. ' Y' .. ". ,. - r r,3J.• b1:{ \ 3 5: ! t 5�b i.�£1 aM tt copy of this ins „action report to the Approving .",'? t � h r The,system Inspector shall submit a co p , Authority within thirty; (30j',days of completing this inspectionn if:the�system;�� r the ins ector land-the is a shared system or has'a design flow of 10,000 gpd or,greateu, p f '00 system owner.shall submit the report to the appropriate Fregional office Yor the 7�1)epartment4 M,4 .1_. z , £ 'R, The original should be sent to the system owner and copy sent yto the hyper,if;applicablea of Environmental Protection. and the approving authority. r_ n, :} ' - - - 4 1 a } f ib'Sk t f'✓rq t 8yi y _..:.. ,',.:,.... ...........u..,...'Yw....s.,......,, ..:A+A.a.fit, ...W v e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owners: Date of Inspection: INSPECTION SUMMARY: Check A, B,C,or D A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303.Any failure criteria not evaluated are indicated below B)SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no, or not determinate (Y,N, or ND). Describe basis of determination in all instances. If"not determinated",explain why not. --- The septic tank is metal,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 conforming septic tank as approved by the Board of Health. ••-- 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 pipe(s). The system will pass inspection if (with approval of the Board of Health): ----• broken pipe(s)are replaced --•-- obstruction is removed SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:A3 Owner : 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 de- termine if the system is failing to protect the public health , safety and the environ- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: --- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. -•- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ---- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,.unless a well water analy- sis 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 norrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. ---- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_L Owner: ,-�,, ; Date of Inspection : D)SYSTEM FAILS (continued) -- 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 over- loaded 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 cesspool or privy is within 100 feet of a surface water supply ortributary 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 ana- lysis. 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ,a a Owner. ',►ti„ ,�� Date of Inspection: E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 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 : --- 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. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CM 5.00 and 6.00. Please, consult the local regional office of the Department for further information. r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3 � Owner: Date of Inspection: Check if the following have been done : -X Pumping information was requested of the owner ,occupant and Board of Health. x-None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the 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 N/A. 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. X All system components, excluding the Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened and the interior of the Sep- tic tank was inspected for conditions of baffles or tees,material of construc- tion, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods 4 The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 613 � x��-�"^� �� � "J�"S Owner: Date of Inspection: RESIDENTIAL: Design flow : 3 3o gallons Number of bedrooms : '3 Number of current residents: c> Garbage grinder(yes or no): No Laundry connected to system(yes or no): A,S Seasonal use(yes or no): K.�o Water meter readings,if available: Last date of occupancy : COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no) Industrial waste holding tank present(yes or no) : Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings,if available: Last date of occupancy : Other: (Describe) ............................................................................................................ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information : _ WY��.�....1�..Ve C1 .. v2"..� Q System pumped as part of inspection lyes or no) :.....K�. ......... if yes, volume pomped: .................... gallons Reasonfor pumping :............................................................................................................ i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a,3 -�ram^N Owner: Date of inspection: TYPE OF SYSTEM •-• Septic tank/distribution box/soil absorption system --- Single cesspool -n- Overflow cesspool --- Privy •-- Shared system (yes or.no)(if yes, attach previous inspection records, if any) .!� Other (explain). . w....t'A: Ca�x .......... APPROXIMATE AGE of all components, date installed (if known) and source of information xm1�1�1 �Q w Cud `� k4g`it .1cI�S QUQ�R�e,� b1 ............... Sewage odors detected when arriving at the site: (yes or no)....N.Q. SEPTIC TANK : ... (locate on site plan Depth below grade: .......... Material of construction: ....... concrete ......... metal ........ FRP ........ other(explain) Dimensions: .................. Sludge depth:............... Distance from top of sludge to bottom of outlet tee or baffle:.............................. Scum thickness:..................... Distance from top of scum to top of outlet tee or baffle: ....................................... Distance from bottom of scum to bottom of outlet tee or baffle :......................... Comments: l (recommendation for pumping , condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage, etc.)...................... . ...................................:............................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ;13 x_ l�_'...—` Owner: Date of inspection: GREASE TRAP : .....1.--n...... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FR P........other(explain).... ...................................................................................... Dimensions:............................... i Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.)........................ ................................................................................................................................................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:.....t�. (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FRP..........other (explain).......... ................................................................................................................................... Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee,condition of alarm and float switches,etc.) ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9.6 OT -\VrNy � 0 wner: Date of inspection: DISTRIBUTION BOX:... (locate on site plan) Depth of liquid level above outlet invert:................... Comment: (note if level and distribution equal evidence of solids carryover, evidence of leakage into orout of box, etc.).................................................................................................................. ................................................................................................................................................ ...................................................................................................................................I............ PUMP CHAMBER:..... (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.).................... ................................................................................................................................................ .................................I.............................................................................................................. SOIL ABSORPTION SYSTEM (SAS):.... (locate on site plan, if possible; excavation not required, but may be approximated by non- intrusive methods) if not determined to be present, explain: .........................................................p...................................................................................... fy"Type: leaching pits,number: .................. leaching chambers, number:........ leaching galleries,number:........... leaching trenches,number , length:..................... leaching fields, number,dimensions:................... overflow cesspool, number:..h... Comments: (note condition of soil , signs of hydraulic failure,level of ponding,condition of vegetation, e A"A'� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: a-3Q --p-� � 1 Owner: ,�, ,�; Date of inspection: CESSPOOLS:...t.�..s.. (locate on site plan) Number and configuration: ....t...,...S.n.. ............ Depth•top of liquid to inlet invert. .. Depth of solids layer: ............ Depth of scum layer: .C��. . ...C.essP 1........... Dimensions of cesspool: ... ....... Materials of construction: . c.ox c Indicator of ground water: NAQ........... inflow (cesspool must be pumped as pa ,of ins ection) ......... ............................................................................ ` Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, 0-6 CA- PR IVY : .... .. (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) . ...................................................................................................................................... f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : Owner: rc� Date of inspection: VA7-C" k SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100'. ►c cx� ��I csve w GL�oZ�o i Q t 1:4 a� a A �L A 1 c3 s �l>b fs r►1Ci1 Gu tsQ,..F l G'.+.'y DEPTH TO GROUNDWATER: Depth to groundwater: !.o.:Xafeet Method of determination or approximative: C71e.C1,.06 t.. t�.wrn►n tC1ca.r,... ..v.�...�.'Zec+�rac�►.c�„Q..>�?Q. c 1�t�dl�c��G��c� ..?a .. ...................... �6. \ 1 4 t ATLANTIC ENVIRONMENTAL P.O.Box 2384 Mashpee,Ma. 02649 0YY Attn: Commonwealth of Massachusetts Date: 11/29/95 Town of Barnstable Board of Health 367 Main Street Hyannis MA 02601 From : Mr Michael DeDecko Po Box 2384 Mashpee MA 02649 Dear Board of Health Official; I certify that I have personnally inspected the sewage disposal system at the following address : 23 Woodland Ave -Hyannis, Mass. The information reported is true, accurate and complete as of the time of the inspection. I have not found any information which indicates that the system fails to adequately protect the public health or the Environment. If you have any questions regarding this inspection,please contact me at this number: (508)477-14-20. Thank you. Sincerely, A- V'C'L4 � I Michael DeDecko phone(508)477-1420 TOP OF FOUNDATION = 43.0' +- PROVIDE CONC. RISER WITH INISH GRADE OVER D-BOx= 40.,4'+ 4"SCHEDULE 40 PVC MIN. SLOPE 1 % FINISHED GRADE OVER INFILTRATION= 40.5' - 40.2' GENERAL NOTES COVER OVER INLET&OUTLET FINISH GRADE OVER TANK EL.= REMOVABLE COVER OVER RISER TO SLOPE @ 2% MIN. 1- UNLESS OTHERWISE NOTED,ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISHED GRADE TO WITHIN 6"OF F.G.- WITHIN 6"OF FINISHED GRADE INSPECTION PORT WITH ACCESS METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL @ FOUNDATION = 41 .6'± -------- 4.-1 .5' -5-DIA. OUTLET(S) BOX TO WITHIN 6"OF F.G. CODE AND ANY APPLICABLE LOCAL RULES. 20"MIN.ACCESS (ONE PER TRENCH) 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE EXIST. SEWER PIPF 9"MIN. 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL 36"MAX. !IN. SYSTEM UNLESS OTHERWISE NOTED. 2" DROP MIN. MIN.SLOPE @ 1% 6" 3' 3- DROP MAX. 3" 9" PROVIDE WATERTIGHT 4. TO PREVENT BREAKOUT,THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN 101, JOINTS (TYP.) ELEVATION =37.93' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A S�12;=7� 4" PVC IN FROM 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF EWER PIPE 14" 38.75' SEPTIC TANK - 4" PVC OUT TO .33' 16"TYP THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. I LEACHING FACILITY (TYP.) 1( 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. *40.0'± 39.00"V 0.90, n10.75Y;"TYP 12" 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. 37.50' \-36.60 (LAID FLAT) -2.875'(34. 7- LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK \-22"ZABEL FILTER MODEL 6"CRUSHED STONE 5.01 (TYP.) FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS 12.0'TO FND #A1801-4x22(GAS MECHANICALLY (TYP.) 11.50' NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH BAFFLE ON BOTTOM) COMPACTED BASE 30.0'(TYP FOR BOTH TRENCHES) 5'MIN. AND DESIGN ENGINEER. 6"CRUSHED STONE 5 OUTLET DISTRIBUTION BOX 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM OF 40.00'ESTABLISHED V R MECHANICALLY TO BE INSTALLED ON A LEVEL STABLE ON A NAIL SET IN UTILITY POLE#210/3 AS SHOWN ON PLAN. COMPACTED BASE dim M M M BASE. FIRST TWO FEET OF OUTLET GROUND WATER ELEV.= < 29.57' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION PROPOSED 1500 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT LENGTH 10' 6' WIDTH 5' 8" DEPTH 5' 8" (DimensbnsperWiggin BIODIFFUSER (PROFILE) BIODIFFUSER (END VIEW, 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES SEPTIC TANK PROFILE Precast Corp.,Pocasset,MA) CROSS SECTION VIEW 12 ARC 36HC (#3616BD) BIODIFFUSERS TO THE DESIGN ENGINEER. *CONTRACTOR T.0 VERIFY ELEVATION NOT TO SCALE DISTRIBUTION BOX DETAIL 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT. NOT TO SCALE NOT TO SCALE ---------------- 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING NOTE: ENTIRE PROPERTY IS LOCATED WITHIN A DEP APPROVED ZONE 11. REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM X/ TEST PIT DATA APPROPRIATE AUTHORITY. 1 PERC NO. 12447 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS I I LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE INSPECTOR- Donald Desmarais, R.S. LO Vow THEY SHALL WITHSTAND H-20 LOADING. EVALUATOR: Michael Pimentel, E.I.T. 13 DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. DATE: December 29, 2008 MAP 269 TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, EXISTING CESSPOOL TO BE PUMPED, FILLED WITH CLEAN ELEV WATER <30.07' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN X SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. __X� PROPOSED 1500 GALLON W I X_ 'X SEPTIC TANK 16- PROPOSED PROJECT IS LOCATED WITHIN: TEXTURAL CLASS: 1 ASSESSOR'S MAP 269 PARCEL 54 4r 16 OWNER OF RECORD: GRACE CORIO& BETTY JO MILLER 105. 081 Fill FEMA FLOOD ZONE C < Loamy Sand Lu IP N;in 18. PLAN REFERENCE: PLAN BOOK 365, PAGE 54 Co 19. co < C-1 (Loose; 10-20% ALL DISTURBED AREAS SHALL BE PESTORED TO ORIGINAL CONDITION. HCA Q Gravel; sorne PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY MAP 269 81 /0 Cobbles) FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY PARCEL52 cly FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. o co 0 EXISTING U) C-2 Coarse Sand CID 3-BEDROOM 2.5Y 6/6 DWELLING WALK f No Mottling, Standing orWeeping Observed No E3X-s%g co DESIGN DATA LEGEND 0 Lu TEST PIT DATA co co NUMBER OF BEDROOMS(DESIGN) 3 50xO EXISTING SPOT GRADE TP 2 if I INSPECTOR: Donald Desmarais, R.S. 40.4' �0' DESIGN FLOW 110 GAUDAY/BEDROOM 50 EXISTING CONTOUR Z EVALUATOR: Michael Pimentel, E.I.T. SC CIS _j DATE: December 29, 2008 660 PROPOSED CONTOUR SHED 6 USE PROPOSED 1,500 GALLON SEPTIC TANK ELEV TOP 40.40' O/H/W EXISTING OVER HEAD UTILITIES 0 ELEV WATER <29.57' -W-W EXISTING WATER LINE (4 PERC RATE TEST PIT LOCATION INSTALL 12 - ARC 36HC (#3616BD) BIODIFFUSERS DEPTH OF PERC EXISTING CESSPOOL 0 Benchmark SYSTEM CAPACITY I TEXTURAL CLASS: 1 GRAVEL DRIVE 00 Nail Set in Utility Pole C). CNI. PROPOSED 1,500 GALLON SEPTIC TANK Approx. M.S.L. (TOTAL L.F.OF BIODIFFUSERS)(7.8 SF/LF)(0.74 GPD/SQ.FT.)= GPD 0. Fill A 4' Loamy Sand 40.07' 13 PROPOSED DISTRIBUTION BOX (6 BIODIFFUSERS EACH TRENCH) S74-3a, Loamy Sand PROPOSED ARC 36HC(#3616BD) BIODIFFUSER PROPOSED INSPECTION PORT (TYP OF 2) TOTAL NUMBER OF COUPLINGS: 0 32" 37.73' UP 210/3 TOTAL LEACHING AREA: 468.0 SQ.FT. Coarse Sand REV. DATE BY DESCRIPTION TOTAL LEACHING CAPACITY: 346.3 GALJDAY C-1 2.5Y 66 PROPOSED SEPTIC SYSTEM -UPGRADE Gravel; scme PARCEL53 EFFECTIVE LEACHING AREA OF 7.80 SF/LF OBTAINED FROM THE Cobbles) PREPARED FOR:. DEPARTMENT OF ENVIRONMENTAL PROTECTION APPROVAL LETTER 80" 33.73' CAPEWIDE ENTERPRISES "MODIFIED CERTIFICATION FOR GENERAL USE" ISSUED TO ADVANCED DRAINAGE SYSTEMS, INC. ON OCTOBER 3, 2003 (LAST MODIFIED JULY 23, 2008). TRANSMITTAL NUMBER W000052. C-2 Coarse Sand LOCATED AT SWING-TIES 2.5Y 6/6 23 WOODLAND AVENUE SEPTIC COVER OUT(2) 188, 20.9' No Mottling, Standing or Veeping Observed 0F AU JOH L PREPARED BY: BIODIFFUSER CORNER(3) 27.8' 10.11 RESERVED FOR BOARD OF HEALTH USE CHU, R. JC ENGINEERING, INC. NOTE: �� N~��B�~ PLAN ~�Q �� 0� U 1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG SITE�� N�=N ��kU�� ~�. � " °�� � �~° °" � y 508.273.0377 THE TOP E OF EACH SEPTIC SYSTEM COMPONENT. I Designed By:MCP Checked By:JLC JOB No.1549 __-__ -----------____--_-_-_----------- __-__ -__- . ___-__-__________-________'_�_______