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HomeMy WebLinkAbout0122 BACON ROAD - Health 122 Bacon Road Hyannis A 309 039 G a �i Y a H '6 Q r it TOWN.OF BARNSTABLE '- LOCATION 12 Z AACOV J ROA 0 SEWAGE # 9603397 VILLAGE P Ji* ASSESSOR'S MAP&LOT- INSTALLER'S NAME&PHONE NO. 56 So =77 7' SEPTIC TANK CAPACITY 1560 LEACHING FACIL=: (type) 330 C'V I��C (size) NO.OF BEDROOMS 3 BUILDER OR OWNER -6 uJ u Rc. PERMTTDATE: 9 I _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 _ Q i - i O � _ G gel �S No. Fee 5 0 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Mitpool *pztem Cone;trurtion Permit Application for a Permit to Construct( . )Repair( x)Upgrade( )Abandon( ) Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 122 Bacon Rd Hyannis Dietger Langenberg Assessor's Map/Parcel 309-39 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. W.E. Robinson Septic C.R. Short P.O. Box 1089 Box 1044 P ervtlle S. Dennis Type of Bud mg: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ho) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Re pa"* or Alterations Answer when applicable Install a new Title 5 septic system to plans of M'. Short Plan # 1 -949 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by th' Boaz of Health. �q Sig Date Application Approved b Date LQ o 3 Application Disapproved for the following reasons Permit No. 3 "31 Date Issued --------------------------------------- Y. _ :;..-•-�+rv._`.k s.:..,......` -.:n.w- - w.+r+:'.�- - -.'.n c.'"`+'..w..Y'"i.-V -. ...«-.� t„ A r J No. Fee�i fl 00 ,y�.. � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pprication for Digpogar *pgtem Construction Permit Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 122 Bacon Rd , Hyannis Dietger Langenberg Assessor's Map/Parcel 30 —3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. W.E. Robinson Septic C.R. Short P.O. Box 1089- Box 1044 DenniS Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ho) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil t Nature of'Repair$or Alter tions(Answe when a p cable Install anew Title 5 septic system to p ' ans of C.H. snort F.Lan — Date last inspected: Agreement: + The undersigned agrees to ensure the constructionand maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thlsBoard of Health.' Sig Date Application Approved b �A�� Date Application Disapproved for the following reasons Permit No. 3 --3- Date Issued --------------------------------------- Langenberg THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal Syst&n Constructed( )Repaired(x )Upgraded Abandoned )by W.E. Robinson ..Septic Service at 1 �2 Bacon Rd Hyannis has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2-nd 3- 3q 7 dated �— 0-U 3 Installer Designer The issuance of t Is pe it shall not be construed as a guarantee that the system ct m"n�dfned�� Date 17 Inspector No."'.`'.�- � � !� --------------------.-----Fee 50.00 Langenberg THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwi!6pool *pgtem Con5truction Permit Permission is hereby granted to Construct( )Repair(x)Upgrade( )Abandon( ) System located at 122 Bacon Rd Hyannis and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. - i Provided:Construction must be completed within three years of the date off this permit.Date:_ 12 I 10 3 Approved by Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i; Property Address Owner Owner's Name information is 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: A. General Information When filling out forms on the computer, use 1. Inspector: I 3� only the tab key to move your cursor-do not Name of inspector use the return r key. T wy C,OrpDyr�,e►�s i.�s, �n0�',�fsy�<f Company Name Company Address /y1.diYSF/fCy. /yp,Ss O�oy� City/Town State Zip Code Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed.based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: �( Passes, ❑ Conditionally Passes ❑ Fails '❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)'within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 god 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. lID :Sins•11/10 Title 5 Offic al Inspectio o Subsurface Sewage Dis osal Sys •Page 1 of 17 aN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for 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 .10 CMR 15,303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below, Comments: B) System Conditionally Passes: 11A ❑ 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): :Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pace 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspecti0 F®rn1 Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments Property Address �2a�F.2T 13�rz� Owner Owner's Name information is GIZ'F/1Z required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cone.). 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(,$) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board.of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt-marsh t5ins-11/10 Title 5 Official Inspection Forth'Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /g2 �vLD.c! 5T Property Address �— Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) N4 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 '/z day flow Sins•11110 Title 5 official Inspection Form:Subsurface Sewaoe•Disposal System•Page 4 of 17 Commom alth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �w„ ��� ly/��D•� ST Property Address Owner Owner's Name information is J� �h/!S /�j�st• G 24 D/ required for 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. ❑ ❑y� Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑N,¢ Any portion of a cesspool or privy is within a.Zone 1 of a public well. ❑ ❑//,4 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑y _ 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. *4 For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 AltCD,c/ ST Property Address Owner Owner's Name information is required for �T` every page. CityfT'own 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? ElHave large volumes of water been introduced to the system recently or as part of 19 this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available_note as N/A) 2 ❑ . 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: [A ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Florio Conditions: Number of bedrooms (design): -2 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): :Sins•11110 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 Property Address yy�� Owner Owner's Name information is �,a�y�s 6?�p/ Gl2Q�'iz required for � every page. City/Town State Zip Code Date of Inspection D. System Information Description: y� Number of current residents: D 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 A11A Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes 5? No Last date of occupancy: 4111' O c G y/&,a Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on.310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ :Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name informations ��/ �,c�/�s /yj�ss• D2 Lam/ G�28J/Z required for / every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) AIX Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection.? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: ,Type of.System: [� Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy . ❑ Shared system.(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Sins•11110 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 Property Address Owner Owner's Namel` information is required for l7� �ylS lf*4fS• 624. cs/28�/z 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: Were sewage odors detected when arriving at the site? ❑ Yes © No Building Sewer(locate on site plan): ?L � Depth below grade: feet Material of construction: cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet P41 Comments(on condition of joints, venting, evidence of leakage, etc.): li11 $4 ►V Laao ► 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 5Vd--.,V,110' >3t> CIOy Dimensions: - y�, Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Z,2.2 1010VoX/ -57 Property Address Owner Owner's Name required for is . �/<S /�'If�SS d 2G0/ ��zy//Z required for , 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 D " G� Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle l9 �g,�SN�/�✓� sn cis 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.): lwr.G o c v, Z/ow/0 4 EV f t �l v erAr de"W/TlrT y No E 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.. :Sins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Forma Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 '/"Cow 5r Property Address Owner Owner's Name / information is Ay/A�llll.S /f',�lfS a�GOt GIZB'�/L required for ' every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) /vd Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): /vb'YF 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 :Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is y �yls �� � D2 6 D 41ZrllZ required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Ha�F 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.): NOA/f 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: Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address <. Owner Owner's Name information is ' Lf,,��y/ required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: � leaching galleries number: ❑ leaching trenches number, length: ❑ 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.): �D • ,, I r �• SO 14. /S Zi4'�S►jA O/2 t/�Gl1It�/O�`i IJi�f 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 Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form F. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 104/3 f:W /5G/,2IC Owner Owner's Name information is required for 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.): .�d ke 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.): :Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /�'2 a3.�o.�/ �• Property Address Owner Owner's Name/� information is �7,/����s ,I�//I�� Q2lvd/ lo/?p,/Z required for , every page. City/Town 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: E hand-sketch in the area below drawing attached separately. 5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: © Check Slope © Surface water /1;:W1 Check cellar © Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ 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)❑ ( t h o umentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: d 12 1 /�fo. ,�11v Aff a Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts -Title 5 Official Inspection F®r Subsurface Sewage Disposal System Form = Not for Voluntary Assessments Property Address Owner Owner's Name / information is required for l! every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Ek 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 fins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Your 1 11 and HoWit, ! It is important to understand how your system works and how this treatment affects it in order to protect your investinent. The typical system consists of three (3) main components. The Septic Tank The Distribution Box ® The Drainfield The Septic Tank Waste exits.the house and enters the septic tank where solids settle to the bottom, grease and scum from the household detergents float to the top, and liquids stay in between. The solids that settle create their own bacte- ria which decompose the solids naturally. There is no need to.add additional enzymes and bacteria to the tank. The tank eventually fills with solids and scum requiring it to be pumped. A septic should be pumped every two (2) years. The Drainfield The liquid (gray water) flows to the distribution box where it is evenly dispersed into the drainfield. Finally, the drainfield begins treating the gray water. Microorganisms in the soil consume organic pollutants in the gray water and the pure water is absorbed by the ground below. How Problems Start From the first day of use, the drainfield of your septic system begins to deteriorate. Some sol.ids, grease, and scum always pass through the septic tank into the laterals. This is because of natural solu- bility or the lack of setting time in the septic tank during periods of heavy use. Problems especially arise when the septic system is not maintained and the septic tank fills with solids and scum that overflow into the drainfield. As the drainfield becomes clogged, the water flow becomes restricted. Since the water cannot drain into the soil, it filters upward causing ponding, foul odors, wet spots in the yard, and an unhealthy envi- What Causes Problems What you don't read about is that bacteria has a waste called biomat, and they also create a gas, bacteria eats human waste. It does not eat, hair, wool, polyester and other particles. The biomat is like grease. The gas cre- ates bubbles and.this causes particles.to float up the T and into the distribution box and into the leeching fa- cility,.plugging up the stone. Septic tanks should be pumped every two (2) years. Cesspool —esspools were made by digging a hole in the ground and walls were made of stone then later on they were wilt with concrete blocks. The waste entered the cesspool, and solids settled to the bottom, the liquids seeped )ut the sides into the soil. Cesspools should be pumped every year. State Environmental Code Title V Chap, 5 Inspection Procedures :guidance on Completing Inspection Form Part A Certification. [fie Certification Section has two principal functions. First it provides identification information on the property being nspected and the inspector. Second, it presents the results of the inspection relative to the failure criteria outlined in 310 :MR 15:303. In the certification statement,the inspector is certifying that the conditions existing at the time of inspection xe accurately presented in the inspection report. The inspector is not certifying that the system is adequate for the current ise of the system nor for the future'use of the system. TONY CAPONIGRO 216 North Main Street Mansfield, MA 02048 Title V Inspections AsBuilt Page 1 of 1 TOWN OF ARNSTABLE LOCATION Z 32 13,geah X'o SEWAGE# 200S VILLAGE ��,4e I5 ASSESSOR'S MAP&PARCEL 09-38 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY /SoD LEACHING FACILITY:(type) /S raX5 (size) X 1 NO.OF,BEDROOMS —�2 OWNER PERMIT DATE:_9 — l7-0$ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility.(If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ,� FURNISHED BY H S E r,D,'! S� n � LjIgCoH 40-W http://issgl2/intranet/propdata/prebuilt.aspx?mappar=309038&seq=1 6/28/2012 TOWN OF BARNSTABLE LOCATION 1 Z 2 ACB`"J SEWAGE# � ASSESSOR'S MAP&LOT 2t-;— 3 VILLAGE SoSt-77 S'-�7 7 �- INSTALLER'S NAME&PHONE .O. "i SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 3 . BUILDER OR OWNER -we--hit'eo- t^t J PERMTTDATE: i COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within300 feet of leaching facility) / Furnished by y�AL � � �c0��l y � . Pr i i r I i i j f 7, OIL­71 s m4m LAR"" DATE,�Or '20,ft-' MINIMUM -TF R. 0' SOIL -ST DONE B Y VWQ. "ILM 'TOP OF�,," OUNDAt IN 0N 10 'OR"CRAWL: SPA TNttSED�BY, X tLE4N ,-SA_ MUM FROM SLAB: 16 Flti,-IOIN 1,0000 :fT ND Imum (ASS tx �",Hopfz I TEXTURE �COLOR MOTIT, OTHER MIN� PITCHA ILI _E ­HOLt ERVATION P11 OBS PE: MEIJ)� lb TION �Rs LOAVI JAND SEED 46 pvc� �co PERCOLA-20 PAT 4",,SCHEDULI,. /8", PER DEPTH LATLK GENDO , t: `E ISTING I -M71/2' -EVAtON' '06- 0 X POT tL AN, . ..... )q.75 ,MAY, ',-EXiSMO�CONTOUR 4 CAST: PIPE 8�40, MIN FINAL SPO fROW 'T ELEVAtIO 0 J­ Ov _A: LOAMY SAND 10YRS/V .(OP,900AL)MNIMU, R FIN U I:UVVN WA X W ) ­_ '9 9 LO MY�SAND I YR NE fl-Oi U -FILTER UTILITY POLE SOIL TEST LOCATIQN ,� PITCH 1/4 P, FT L A IF �7, CATCH 'BASIN A t tAS LINE om 413ING"' -TON., �y N AND- RE--;PIPED -E LtV E RAIS�D`�:' �i.'00 Nn - '' I I CLEAN, T, COARSE SAND ,, .,'94,00 sum 0 EL V. �BGA LE E AF MEDIUM D 1 VID OUTLET. AN- WATE STbN DFP -BE PLACED ON PRW'�BASE) to BE, R 71 80X UL ON AS'NEEDM,' I ull 46 W!TH (TO E iN I�44C2_ 14 INCHES, 4, FET, ANiCH NCH WA NO TERtNCOUNTtPED' AT T -'MORE., HAN O�C,OUTLET 5 F F14 INCHES WELL E 19 HES ZONE X­ LAII "SYSTEM X, ONS OEIGNI;CA 8 FEE .6n,c' ,TANK 500' GALLON '6 FEET - 1 : , "', <TO KACED�,OR fIRM 9ASE -,:S 01 L' ASSORP NLA EET 29 INC SEP INDEX T; 3/4 TO I J/2", ft_­ 'STONE ''DbUBLE- WASHED ADJ#JT MS 2 VOSTING-�S NUMBER, r BtM6 lRtC ,OF'PlNES SILT 'GAR8AG UNIT ALLO T_ _WED ATER TABLE Ell�V� -GAL/9R.,,or00.'X SE TCR JASL�, SEWA BR 'TOTAL ESTIMATED FLOW PROBABLE W GE ;`DISPOSAL: _PROFILE 8' RVED 'WA NO -SCALE -n c T 0 BOTTOM OF � 'ST HOLE &LOQ-o� REQUIRED",$EP PACITY- TIC TANK,tA GAL- T TO ELEV,' ACTUAL sr s Ep ANK�, �SOIL CL PtOLATION "'RATE MIN,/�N' DESIGN PE, -EFFLUEN LOADING RA %3 T -AREA, LtACHING' 6 'Y .6 .21 ,LEACHING'oCAFlAl RATE)CITY �493 X'0 74 RESERVE LEAC14ING CAPA 1 NOTE ALS SH LL�CON "I.,ALLiir.WORKMANSHIP Ak ��MATi ' A TO 0 t P' 11 '5, ND l� LES ,AN b �RtGtj �4E iE'TOWN �RU LATIONS�tdq, DISPOSAL OF,S WAG Lt,-,tOVERS,,-TO�SANITAR�f'ONt'Tg SHALL,bE t T, u G k To A THIN �67, FI NISHED.GRADr" $HALL.13E 3. ALL.C�OMPONENTS'�OF THE, N - 'LESS *EY4 :WTHSTANDNG. +4 DiNdUN, FT OFIDRIVES -AREAS, L U$51)'UNDER,OR OF RIVES 0 lEA SH BRING COVERS ANY,WSON�Y;U NITS USED to TO' GRAB.,BE, MORTARtO lN`PCACF_. ON HAS-'BEEN,' Ab&,,-,AS ' C ONA� )"COMPLIANCE 0,000 'S.F.d. s-, 0 N z6Ni tR�,/,APPL Tli HORI 'OSTAIN SUCH,,DETERWN All ON�,,f, ROM APPROPRIATE-z-AG-T k I -OR TtA EXCAVATION--00 AbT UTILITIES HOWN ARE APPROXIMATEI�.ONLY, T I 344--�-7233 AT LLIASt-- �SAFE ' A ' us— IS TO-CALL 0 99.2 TO-COMMENCfNG­Wd0K'ON`S[tE-,- A. ACTOR is_10� VERIF`Y-GRADES tLEVXTf0NS,­AS S 7.,,CONTR SITE"CONOITIONS, PR SITE.�-.MY VARIATION. IOR ' O�' 'AM 'BROUGHT TO 11AE W[ON OF��THE'DESION ENG 'EER­ ,, I S,-TO,�'BE IMMEDIATEL ro 7ONE OARAVE' IN FLOOD , PARCt IS 'SHOWN A LOT IS :ON ASSESSORS MAP`.����,� S �PAR .2 CtL 309' 'L UN VED M AL W 046tR WO 'bE :PtM'O SUlfAkk MATERIALIHA-G,_ �'FOR A mmMum �'OF'S rFEt FROM SYSTEw! -SORPTION AROUND..THE $OfL!-,,AE3 AND B5.-RtPLACED VTH''SAND�AS SPECIFIED 14 310 CMR-,-15.255.:,(,3) v BELOW t�A PIPEANVERT 55� ENCOUNTERED N"vr,4" 71 S�STEM TO BE'^,P0MPtD A�D,�fILLEDi'r SAND M VtWA tl; tXIS',nNG SEP C 77, OR' EMO-Wu- EXIS NG SHOR T TANK -2., A, ZABEL Al'800,FILTER S',TO Alttbl' CIVIL No.274 -AP �E No.274 HEA lu �ROV :B.0A NAL 5 �A DATE LN I 9 #2 4722 p4ROPOSD SEP TIC D E SIGN R C3 ANGE B G, 0 DIET ER 0 ........... 4,0 0 7�' 122 ' 13AC. 'HY NNIS p CRNG_:R�:, s JfORTp R OAD 4 T4ESTERW 235:�GREA HYANNIS 'EAST 4, D N A$S.:, ELEJV4ENTARY BF_ SE 76AL� Joe No L TIAI REV. SH � . E�ET L0CATf0N , _MAP_ 9 49 Ln961 100 ' 0