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HomeMy WebLinkAbout0894 OLD POST ROAD (CT & MM) - Health 894 Old Post Road Cotuit A= 073-005 -- f� Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 894 Old Post Road Property Address Peter& Deborah Ryder Owner Owner's Namei information is ✓ Ma 02535 11/28/2020w. required for every COtUIt page. CitylTown State Zip Code Date of Inspection P 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 S/# /go(q filling out forms on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor do not S M Jones Title V Septic Inspection use the return Company Name key` 74 Beldan Lane Company Address Centerville Ma 02632 C1 rown State Zip Code 774-248-4850 smjonestitle5@gmaii.com, S14522 sean@smjonestitle5.com License Number B. Certification I cerfify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails -` 11/28/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 official Inspection Form:subsurface Sewage Disposal system-Page 1 or 18 t5insp.doc•rev.A28=18 1 f Commonwealth of Massachusetts Title 5 official Inspection Form p Subsurface Sewage Disposals System Form-Not for Voluntary Assessments 894 Old Post Road Property.Address Peter&Deborah Ryder Owner Owner's Name 02635 11/28I2020 information is COtuit Ma required for every Cityrl'own State Zip Code Date of inspection page. 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: The property located at 894 Old Post Rd Cotuit is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 28 Hi Cap Infiltrators. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 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): Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 t5insp.doc•rev.726/2018 ill t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 894 Old Post Road Property Address Peter&Deborah Ryder Owner Owner's Name information is Cotuit Ma 02635 11/28/2020 required for every City/Town Zip Code Date of Inspection Page 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: El 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: Title 5 officisi inspection Form Subsurface Sewage Disposal system Page 3 of.18 i5insp.doc•rev.712Eiwia -,a cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 894 Old Post Road Property Address Peter&Deborah Ryder Owner Owners Name information is Cotuit Ma 02635 11/28/2020 required for every State Zip Code Date of Inspection page CitylTown 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. [j 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, provi ded 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Title 5 offlcial Inspection Forth:Subswfaoe Sewage Disposal System•Page 4 of 18 t5insp.doc•rev.U26=18 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 894 Old Post Road Property Address Peter&Deborah Ryder Owner Owner's Name information is Cotuit Ma 02635 11/28/2020 required for every Cy�Tn state Zip Code Date of Inspection page- C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow El ® 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. ❑ ® u Any portion of a cesspool or privy is within350 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 now 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 0 ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ El Area system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well Title 5 ormcial Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 t5msp.doc•rev.712612078 4 Commonwealth of Massachusetts Title 5 official Inspection Form Assessments Subsurface Sewage Disposal System Form Not for Voluntary c 894 Old Post Road Property Address Peter&Deborah Ryder Owner Owner's Name 11/28/2020 information is Cotuit Ma 02635 required for every n State Zip Code Date of Inspection C otuit page. C. Inspection Summary (cunt.) 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 C.4 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 at!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? ® El available as built plans of the system obtained and examined?(If they were not available note as NIA) ❑ Was the facility or dwelling inspected for signs of sewage backup? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes on of the baffles or teem interior matey al of construction, tank inspected for the condition dimensions, depth of liquid, depth of sludge and depth of scum? ® El information 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)] Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 6 Of 16 t5insp.doc-rev.7P2CMI B c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 894 Old Post Road Property Address Peter&Deborah Ryder Owner Owner's Name information is Cotuit Ma 02635 11/28/2020 required for every Cityrrown State Zip Code Date of Inspection page. D. System Information 1. Residential Flow Conditions: 5 Number of bedrooms (design): 5 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for,example: 110 gpd x#of bedrooms): 550 gpd . Description: I i unknown Number of current residents: Does residence have a garbage grinder? El Yes 0 No Does residence have a water treatment unit? El Yes ® Na I If yes,discharges to: Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: Date -nue 5 official Inspection Form:Subsurface Sewage Disposal System Page 7 of 18 t5hsp.00e•rev.712WO18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 894 Old Post Road Property Address Peter&Deborah Ryder Owner Owners Name 11/28/2020 information is Cotuit Ma Q2635 required for every cotuown State Zip Code Date of inspection page. di D. System Information (cont.) 2. CommerciaUlndustrial 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.): ❑ Yes ❑ No Grease trap present? 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: tank pumped after inspection Source of information: Was system pumped as part of the inspection? Yes ❑ No 1500 If yes,volume pumped: gallons size of tank How was quantity pumped determined? routine maintenance Reason for pumping: Title 5 Official inspection Form:Subsurface Sewage Disposal system•Page 8 of 1.8 t5insp.doc•rev.7126/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 894 Old Post Road Property Address Peter&Deborah Ryder Owner Owner's Name information is Ma 02635 11/28/2020 required for every COtUIt State Zip Code Date of Inspection page City/Town D. System Information (cunt.) 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the 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: system installed 3/20/2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2 Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from,private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): Joints in good condition, no leakage,vented through roof. tsinsp.doo•rev-7l26Y2018 Title s official Inspection Form:Subsurface sewage Disposal System•Page 9 of 18 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,3 894 Old Post Road Property Address Peter& Deborah Ryder Owner Owner's Name 02635 11/28/2020 t information is COtUI Ma required for every C otui wn State Zip Code Date of Inspection page. rmation (cont.) D. System Info 6. Septic Tank(locate on site plan): 1.5 Depth below grade: feet Material of construction: concrete metal ❑fiberglass ❑ polyethylene El other(explain) ® ❑ f I If tank is metal, list age: years S Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1500 gallons 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 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.): er Tank was pu lets andr1 outletinspec wateron andleveluwas eshold beven with of ut et ione agan nvert.Tank waso Tank has 3 in structurally maintenance. sound and not leaking. Title s official Inspection Form:Subsurface Sewage Disposal system'Page 10 of 18 t5insp.doc•rev.7%26=18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 894 Old Post Road Property Address Peter&Deborah Ruder_ Owner Owner's Name information is Ma 02635 11/28/2020 required for every b7d State Zip Code Date of Inspection page Citylrown 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 Tide 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 t5insp.doc ray.U2612018 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 894 Old Post Road Property Address Peter&Deborah Ryder Owner owner's Name 02635 11/2$/2020 information is Cotuit Ma required for every C otuit n State Zip Code Date of Inspection page. 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.): contract(required). Is copy attached? ❑ Yes ❑ No ` ant pum ping q urr Attach copy of c p p 9 9. Distribution Box(if present must be opened) (locate on site plan): or' 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.): Distribution box was level and in good condition with no rot. Water level was even with outlet inverts with no signs of past backup. Titte s ofrrcial inspection Form:Subsurface Sewage Disposal System page 12 of 18 tsinsp.doc•rev.712612018 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 894 Old Post Road Property Address Peter&Deborah Ryder Owner Owner's Name information is Cotuit Ma 02635 1.1/28/2020 required for every Cityrrown State Zip Code Date of Inspection page. 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: 28 Hi Cap ® leaching chambers number. Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: [] leaching fields number, dimensions: ❑ overflow cesspool number: [� innovative/alternative.system Type/name of technology: Title 5 Official Inspection Forth:subsurface Sewage Disposal System•Page 13 of 18 t5insp.doc rev.712612018 Commonwealth of Massachusetts Title 5 Official Inspection Form em Form Not for Voluntary Assessments Subsurface Sewage Disposal Syst 894 Old Post Road Property Address Peter&Deborah R der Owner Owner's Name information is Cotuit Ma 02635 11/28/2020 required for every City/Town State Zip Code Date of Inspection page. 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.): Leaching facility was video inspected from d-box and was found with 3"standing water and no signs of past overloading. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): p Number and conf juration - 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.): Tide 5 official inspection Form:Subsurface sewage Disposal System-Page 14 of 18' t5insp.doc.rev.7f2612618 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 894 Old Post Road Property Address Peter&Deborah Ryder Owner Owner's Name information is Cotuit Ma 02635 11/28/2020 required for every CityRown State Zip Code Date of Inspection page- 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.): 4 Title 5 Offc al Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 t5insp:doc-rev.7@6fm18 Commonweatth of Massachusetts Ti Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 894 Old Post Road Property Address Peter&Deborah Ryder Owner Owner's Name information is Cotuit Ma 02635 11/28/2020 required for every Cityr ow state Zip Code Date of inspection page. 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 r f Qc ' k q A B � i2e a 31 39` P 5- y J -MW*' G y5= 7 y7 fps. Tithe s omciai Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 t5 nsp.doc-rev.726=18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 894 Old Post Road Property Address ` Peter&Deborah Ryder Owner Owner's Name information is Cotuit Ma 02635 11/28/2020 required for every state Zip Code Date of Inspection page. City/Town D. System Information (cont.) 15. Site Exam: ❑ Check Slope El Surfac e water Check cellar ❑ Shallow wells 12'+ Estimated depth to high ground water: fee Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators;-installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before fling this Inspection Report, please see Report Completeness Checklist on next page. t5insp doc-rev.772WD18 Tide 5 Official Inspection Form:subsurface sewage Disposal system-Page 17 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form VM Subsurface,Sewage Disposal System Form-Not for Voluntary Assessments 894 Old Post Road - Property Address Peter&Deborah Ryder Owner Owner's Name information is Cotuit Ma 02635 11/28/2020 required for every page Cityfrown 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 t5irnsp doc-rev.7/2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE LOCATION , yqq 01611,90 S)` g4 SEWAGE#. o_200r9— 0L/�_ VILLAGE ASSESSOR'S MAP&PARCEL 73 1o05- INSTALLER'S NAME&PHONE NO. i),C, Ru '428 '7S795 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) R!t�(size) ,l3.�}X yy, 7s NO. OF BEDROOMS OWNER & PERMIT DATE: 3- 3 ' 0 ct COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY SU r, Vk- !itk ; ec J\ " s s old POf Ad, TOWN OF BARNSTABLE 'LOCATION X'y�/ /Jj�/ s SEWAGE#. d OOcf- Dyj— .VILLAGE ASSESSOR'S MAP&PARCEL 73 /0o5- INSTALLER'S NAME&PHONE NO. J , Ay SEPTIC TANK CAPACITY _LS-,gg LEACHING FACILITY:(type) ;rye.. K tars —a& y' (size) /3.�3 X yy 75- NO.OF BEDROOMS OWNER ,off PERMIT DATE: ,3-• j— D `� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and LeachingFacility Feet ty(If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within Feet 300 feet of leaching facility) FURNISHED BY Feet fi K • �r J QG h 5ooy ?uh k 0 a 3 / ' 3Y .... P � - 3 gg y� - y3 0 I y�y 7y - y7� �o Town of Barnstable �'� -P# Department of Regulatory Services MUMSUBM Public Health Division Date b z t639 �� 200 Main Street,Hyannis MA 02601 r Date Scheduled Time , Fee Pd. \g(? .:. Soil Suitability Assessment for Sewage isposal Performed By: -�t�L2_ Witnessed y: LOCATION& GENERAL INFORMATIO Location Address 13 44 u Ln V U � Owner's Name Address 1`!`Z (k0 J (✓�1 �-4\l�l� Assessor's Map/Parcel: Engineer's Na O �f=�C--r�•.i1L�J► 't�i-� me NEW CONSTRUCTION REPAIR . v Telephone# �� ✓ Land Use j Slopes(%) / _ Surface Stones Distances from: Open Water Body i O A Possible Wet Area� tuft Drinking Water Well. ft Drainage Way ft Property Line _ yfL 'Other g SKETCH:(Street name,dimensions of lot,.exact locations of test holes&perc tests,locate wetlands in proximity to holes) 01 7 , L:l , o Parent material(geologic) Depthto Bedrock 7 5,0 1 Depth to Groundwater. Standing Water in Hole: iZvL.. Weeping from Pit Nee - Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER FABLE Method Used: Depth Observall standing in obs.hole: in, Depth to soil mottles: in, Depth to weeping from side of obs.hole. in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level,�a Adj,factor Adj.Clroundwaterbevel,,,� PERCOLATION TEST Dote Time..�.:_A r Observation Hole# A— Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ i O Time(9"•6" End Pre-soak -Rate Min./Inch G Z Site Suitability Assessment: Site P ssed 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:\SEPTICTERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil er Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Coqsistencv.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil ther Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. n4stency,% el AI o65rs '�ArE. . .S -4 kk 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) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,Wgray 1 Flood Insurance Rate Map: Above 500 year flood boundary No Yes r.�....� Within 500 year boundary No Yes Within 100 year flood boundary No 2 Yes Depth of Naturally occurring Pervious Material Does at least four feet of naturally occurring p4pperv s material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring us material? Certification s I certify that on 3 (date)I have passed the soil evaluator examination approved by the Department of Enviroi mental Protection and that the above analysis was performed by me consistent with . the required training,expertis rid experience described in 310 CMR 15.017. Signature 1 Date o Q:\SEFnC�PBRCFORM.DOC No. �D G �. s Fee ! V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppgication for Mi5po5a[ 4&p9;tem CDtt.5truction Permit Application for a Permit to Construct( ) Repair(4grade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. tiw a Lb o�� �o� Owner's Npme,Address;and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Desiignere'''Name,Address and Tel.No. ,j,G. 9a ffo Loos y� rr�1yT'a_, i J�c fit': p t,6 o C.�i i°0 AW 3.3ef gu s ja 5-4.0 Type of Bu' ding: Dwells No.of Bedrooms Lot Size !j'2 sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 51 0 gpd Design flow provided gpd Plan Date - -L A - O Number of sheets t Revision Date Title �� �y ltlyl�. \' A/ j ~;=DYL oft 4 o L-1--,- \a S-� ErgA? Size of.Septic Tank 1 L9 u Type of S.A.S. t�,t'�z/ ,� lZ,-sk;, LI` Description of Soil �J ti--.�� ��� _6 e, �p -►`Z A-7 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issu�ed by thi �ard �Health. Sig Date Application Approved by Date .�9 Application Disapproved by: Date for the following reasons Permit No. ( . � S Date Issued 3 �_- ------— _------------------------ No. Fee r THE COMMONWEALTH OF MASSACHUSETTS IA° Entered in computer.--Y PUBLIC NEALTH.DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for TDigpont *pgtem Cow5trudion permit Application for a Permit to Construct O Repair, Upgrade O Abandon O -].Complete System El Individual Components '-v os� tZo Location Address or Lot No. ���'t 0 Owner's.Name,Address,and Tel.No. Assessor's K,ap/Parcel -1 - p V Installer's Name,Address,and Tel.No. Design e 's Nam\e,,Address anµ T�/7`No. w� /� ✓ C.. //l9/tea 4 oris�/ pis V ("\T.. A A(., 10�7 <0 67 5-4o — z 3 Type of Building: f Pther g? No. of Bedrooms l_ S� Lot Size 3 `l"11-L- sq. fr. Garbage Grinder kAID --T Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures t I '> Design Flow(min.required) 5 �s� gpd Design flow provided �o gpd Plan Date n'Z - -L O Number of sheets Revision Date _ Title �j 1 Ao\t_ \" Ar "1=�Y��. `t 0 L:Z-7 \ 5"r aAl'- Size of.Septic Tank ► �cJ Type of S.A.S. ' Ir-ILSI /A'-eO CL,., 7=7k�wl.. Description of Soil �Z--_�".. ®�1.. L r9 q LV r1-1.ArT 1 Nature of Repairs or Alterations(Answer when applicable) J t Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this�Board-of Health. Sig`ned�/ I Date Application Approved by \�/ > _��` � Date �` � i Application Disapproved by: �; i { Date for the following reasons Permit No. az) ! Date Issued 37 P,,, w THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( Repaired ( ) Upgraded ( ) Abandoned( )by J. C. ` X9G /;/v r at 9 4/ /d /7 O rl Iq d l-D�tL--�l has,beenconstructed,i.n accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 5 dated Installer J°C �� � Designer r #bedrooms _� Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will fulctiot�'delsigned. ^� r Date . I I _ , Inspector r No. 7 S Fee �CC// THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS �Digpogar *p5tem Con5trUction Permit Permission is hereby granted to Construct ( ) aRe air ( ) Upgrade ( )_ Abandon ( ) System located at S?Ll Old /70 S y /"t 6W (C t/ and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Coonstruc'on must be completed within three years of the date of this permit: Date J/>� Approved bye_ ,:/` .. - .. l'^` - �-.�..-vim..-•-, � ..�-. Town of Barnstable �p THE T Regulatory Services Thomas F. Geiler, Director * BARNSTABLE, MASS, Public Health Division 1639. �0 Thomas McKean,Director 2,00 Main Street,Hyannis,MA 02601 Office:. 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: c,3 —i y—p6( Sewage Permit# ROOy ®L/- Assessor's Map\Parcel Designer: GJ . �;����,% Installer: o;�, ✓ �_ o o _ Address: q 7 G ��►�r, �d �n Address: 20 3321 On was issued a permit to install a (date) (installer) septic system at %h (7� i��nna based on a design drawn by (a ress) dated °Z -- -z.� -- D� (d signer) —� I rtify 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. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required) was inspected and the soils were found satisfactory. ��AAAA OF�As61 ° ��G\�r EaF34 9�, y�o DAVID / (Installer's Signature) MASON m -41 ' s EJ.. COPg __q DOYLE v 9 No.1066 A #37559 i �G/S7E s�N/TARS (D igner's Signature) (Affix esigner's Stamp Here) �a PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 03-09-06.doc - � 2--o � 4 I 4E co rI _ LLZFiL a _ b 1 < N r o 3 d, E rn h 1039 o o O k ( � S 4 CREATED BY: CREATED FOR: PROJECT INFO: t� CURRIE DESIGN N/1 n fe n �SS STAIR OPTION 1 'SCALE DATE 950-Cambridge Street DVN BY, HKD BYi 9 HilltopCircle Medfield MA 02052 D��PQID � Cambridge, MA OZ141 '-` .r-�" RMC RMC 781.344.5810 fax 781.344.4074 Tel 1-877-2VINFEN JOB NUMBER p DATE DESCRIPTION _Cb. Z Fes; 1-617-441-1858 4 V-9 1/4" V.I.F. ND FLOOR EXISTING ELEV = 109'-811 TREAD DEPTH COULD BE 9.25" MIN 10' i 4 3/4" FIFIF EIE 7L= EIJI .0. PATIO (EXI TING) ELEV = 100'- " STAIR SIDE VIEW 1/4 = It-Opp H PRELIMINARY - NOT FOR CONSTRUCTION 6-15-09 CREATED BY: CREATED FOR: PROJECT INFO: CURRIE DESIGN SCALE/ n fe n EGWM UAL OPT�oN 1 SCALE DATE 950 ,Cambridge Street 894 OLD POST RD DVN HYe HKD BYi 9 Hilltop Circle Medfield, MA 02052 Cambridge, MA 02141 RMC RMC 781.344.5810 fax 781.344.4074 Tel 1-877-2VINFEN /� T ' JOB NUMBER- ' p DATE DESCRIPTION Fax 1-617-441-1858 yO'v� MA i { I iE? Vj qe vvv- IV. _0 ® FINISHED GRADE EL. 46.4'f I.P. WITH SCREW TYPE CAP TO WITHIN II 6 20" RISER 20." 6„ 3" OF FINISHED GRADE (4 TYP.) p 0-1 NORTHT7�11TTT1TII GEOTEXTILE FABRIC SEE PLAN VIEW. LL_ Lj Q J BAY INV EL Dia. Dia. 44.4' FINISHED GRADE EL. 46.0'f FIN. GRADE = 46.0' o � 6j �s .-3.5' 6" � O Q 0 0 (LOWEST OF TWO) 7fin < w � o � W � i-i JliJ » a INV EL '= �- INV EL 16 _ a QOc'� Below Flow Line INV E INV EL QU z Q O 4' 41.2b O`o Liquid Level 48" ' (n O 6" Stone 34 CLEAN MEDIUM SAND Q Cn N DISTRIBUTION BOX 6" SEPARATION BETWEEN ROWS (TYP.) � \ale, ILITTLE SLAND PROPOSED 1500 GALLON TANK PRECAST DISTRIBUTION BOX NOTES: 13.83' N �J W5- I- O G INSTALL ON A LEVEL BASE USE FOUR ROWS OF (7) HIGH CAPACITY INFILTRATOR CHAMBERS 00 UU ::D L,O C LJ.�' MAP N86°35'00"E 121.11 MINIMUM WALL THICKNESS = 2" TOTAL CHAMBERS = 28 m Lli 50 MINIMUM INSIDE DIM. = 12" BOTTOM OF SOIL PIT = EL. 34.0' m LL V) OUTLET INVERTS SHALL BE EQUAL TO EACH OTHER AND AT NO GROUND WATER OR w 2" MINIMUM BELOW INLET INVERT. REDOXIMORPHIC FEATURES OBSERVED Q THE DISTRIBUTION LINES FROM THE DISTRIBUTION BOX SHALL o 48 ALL HAVE EQUAL INVERTS AS DETERMINED BY FLOODING THE DISTRIBUTION BOX TO THE HEIGHT OF THE DISTRIBUTION LINE ASSESSORS MAP 73 PARCEL 005 � INVERT AFTER ALL LINES HAVE BEEN SEALED IN PLACE. 4 PVC T - PARCEL sr INVERT ADJUSTMENTS SHALL BE MADE BY FILLING WITH VENT 10DEED REFERENCE: 23220-154 6 DURABLE AND NCNDEFORMABLE MATERIAL PERMANENTLY Ss)� FASTENED TO THE LINE OR RECONSTRUCTING THE LINES FIN. GRADE EL. 46.0'f PLAN REFERENCE: 118-95 5 7 g 2 ± S . F . g 2). UNTIL ALL INVERTS ARE OF EQUAL ELEVATION. ZONING DISTRICT: RF � 3s F OVERLAY DISTRICT: AP & MA ESTUARY Z.O.C. INV. EL. Ao 42.17 MED. MED. FLOOD ZONE: "C' SAND _ - SAND FIRM PANEL: 250001 0018 D If i 6" PANEL REV. DATE: JULY 2, 1992 43.75' LOCUS STREET ADDRESS: 4.75' 894 OLD POST ROAD 36 COTUIT, MA 34 47 2' USE FOUR ROWS OF (7) HIGH CAPACITY INFILTRATOR CHAMBERS o 3 2g TOTAL CHAMBERS = 28 2 ��6 REMOVE BLOCK w 30 x FOUNDATION \ x 46.7' 46.7' ^D \ z \ \ BM: TOP CB FND. 28 O VENT \ \ \\ DATUM:2 GIS± W Q 26 _ \ \ DESIGN DATA: + ^ \ EXISTING FIVE BEDROOM' - NO INCREASED FLOW z TP1 \ \ \ 5 x 110 = 550 GPD REQUIRED FLOW Q o TP2 \ \ USE 28 HIGH CAPACITY INFILTRATOR CHAMBERS 24 61 S2. � � 8 D/B \ \ IN FIELD CONFIGURATION WITHOUT AGGREGATE 26 4" PVC O INSPECTION 46 \ \ (28 x 6.25) x 4.72 SF/LF = 826 SF SEPTIC TANK NOTES: A PORT (4 TYP.) 0 \ \ 826 x 0.74 = 611 GPD TOTAL DESIGN FLOW TEES SHALL BE CONSTRUCTED OF SCHEDULE 40 PVC AND SHALL EXTEND A / PROPOSED o 57' \ \ MINIMUM OF 6" ABOVE THE FLOW LINE OF THE SEPTIC TANK AND BE ON PROPOSED 1500 GALLON INFILTRATOR SEPTIC TANK o �s \ GARBAGE DISPOSAL NOT ALLOWED THE CENTERLINE OF THE SEPTIC TANK LOCATED DIRECTLY UNDER THE N \ FIELD CLEAN-OUT MANHOLE. THE INLET PIPE ELEVATION SHALL BE NO LESS THAN 2" NOR MORE THAN 3" PLATFORM N(O ABOVE THE INVERT ELEVATION OF THE OUTLET PIPE. THE SEPTIC TANK SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL, STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON WHICH \ ISTING 5 6" OF CRUSHED STONE HAS BEEN PLACED TO ENSURE STABILITY AND EX \ c,+ BEDROOM TO PREVENT SETTLING. C' DWELLING THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 12", WITH TWO o RAMP 20 MANHOLES HAVING READILY REMOVABLE IMPERMEABLE COVERS O \ OF DURABLE MATERIAL SHALL BE PROVIDED WITH ACCESS PORTS. \ 45.8' ; THE TANK OUTLET TEE SHALL BE EQUIPPED WITH A GAS BAFFLE. x x O\ v \\ 45.T 46.2' GENERAL NOTES: 46.2' D 1. ALL THE WORKMANSHIP AN MATERIALS SHALL CONFORM TO DEP s�8 \ \ Li TITLE V AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS 00 \ moo. �\ \ O FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2. ACCESS PORTS OVER TANK TEES SHALL BE ACCESSIBLE WITHIN 6" Ex�ST�NG GR \ O \\ z OF FINISHED GRADE. A�fc DRIVE \ \ z 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF \ `r WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10' \ \\ a OF DRIVES OR PARKING. H-20 LOADING SHALL BE USED UNDER OR WITHIN \ 10' OF DRIVES OR PARKING, UNLESS NOTED. 4. THE EXCAVATOR/CONTRACTOR SHALL CALL "DIG SAFE" AND VERIFY THE LOCATION x \ F SITE UTILITIES PRIOR TO ANY EXCAVATION AND SHALL BE RESPONSIBLE FOR 4s.5' \\ \ ��P��H 0F2 � 0 ALL MATTERS RELATING TO ELECTRIC AND/OR GAS EASEMENTS. \ \ o DAVID �y\� � o0 B.5. SEWER PIPES SHALL BE SCHEDULE 40 PVC. (4" DIA. UNLESS OTHERWISE NOTED) \ 6. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE \ o MASON ;` Ln 0 MORTARED IN PLACE. TEST DATE: 02-19-09 \ Fug o _ N Q �� 0 �, No.1066 =i1 �( � U 7. FINISH GRADE SHALL HAVE A MINIMUM SLOPE OF 0.02 FT. PER FOOT. SOIL EVALUATOR: S. DOYLE L- I C� \\ \\ 0 q r> N� 0 O E G E IC 8. EXISTING SYSTEM COMPONENTS IF ANY SHALL BE ABANDONED PER HEALTH AGENT: DONNA MIORANDI TITLE 5 REQUIREMENTS. 761 \ \ (n z w 9. THE EXCAVATOR/CONTRACTOR SHALL BE RESPONSIBLE TO CONTACT DOYLE T.P. #1 PERC <2 M/INCH T.P. #2 PERC <2 M/INCH EXIST. CESSPOOL \ Q � -co 0 AND ASSOCIATES 24 HOURS PRIOR TO ANY REQUIRED INSPECTIONS. EL. 46.0' 0» EL. 46.0' 0" TO BE ABANDONED \ \ Q = cn 10. ALL COMPONENTS SHALL BE MARKED WITH MAGNETIC TAPE OR SL 10YR 3/2 '� �° SL 10YR 3/2 \ \ Z U COMPARABLE MEANS IN ORDER TO LOCATE THEM ONCE BURIED. A A \ Q Q 6 6 BURIED WATER LINE \ \ m v rq "BW LS 10YR 5/6 "BW LS 10YR 5/6 31 .6' \\ \ J � < N 35" (EL. 43.1') 28 (EL. 43.6') EXISTING SPOT ELEV. \ x \ O Q = � Ln C MED. C MED. 59 EXISTING CONTOUR ��` � Frscar.R,c sip `� ao SAND GRAPHIC SCALE , "' SAND � �� � .,, PERC ® 60 EXISTING UTIL/POLE so o 10 zo ao ao I Z DOYLE " W � LLi �. Nc, 37559 Z z 2.5Y 7/3 2.5Y 7/3 f SStoNAc}, O EL. 34.0' EL 36.0' ( IN FEET ) ,F '41 UF1d� IQ CL 132 120 1 inch = 20 ft. (/� J NO G/WATER OR NO G/WATER OR L .V�,,cl Lli REDOXIMORPHIC FEATURES REDOXIMORPHIC FEATURES