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HomeMy WebLinkAbout0360 BISHOPS TERRACE - Health 360 Bishops Terrace Hyannis F/R 250 075 I; f Commonwealth of Massachusetts 0150 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360�1y Bishops Ter. Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is H annis MA 02601 5-2-15 required for every y 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. A. General Information 10 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 EZYaluati y the Local Approving Authority 5-2-15 inspector's signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 360 Bishops Ter. Property Address Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 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: System is in good working order with no sign of failure. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official .Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Bishops Ter. Property Address Bank Owned (Contact David,Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 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): El obstruction is removed El Y El N M 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 1 . Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 360 Bishops Ter. Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 page. Cityfrown 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: F * 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 Y2 day flow t5ins-3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Foern Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Bishops Ter. Property Address Bank Owned (Contact David Holt @ Today Real•Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 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 ❑ ❑ 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-3/13 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 M 360 Bishops Ter. Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facilityor dwelling inspected for signs of sewage back u ? 9 P 9 9 P Was the site inspected for signs® El Was of break out?P 9 ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Bishops Ter. Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder?- ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No 3-2015 Last date of occupancy: Date 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•3/13 Title 5 Official Inspection Form:Subsurface Savage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Bishops Ter. Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe be'ow): General Information Pumping Records: Source of information: N/A 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/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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts A Title 5 official Inspection, Form I o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Bishops Ter, Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 10"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 211 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: 1000 gal Sludge depth: 12" t5ins-3113 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 5 360 Bishops Ter. Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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-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 360 Bishops Ter. Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow- gallons per day � Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): i Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 360 Bishops Ter. Property Address Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from infltrators. Pump Chamber(locate on site plan): Pumps in working order: Ell 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•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official o nspecfioh Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments G1M , 360 Bishops Ter. Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-Infitrators ❑ 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.): Infiltrator leach field in good working order with no sign of back-up into d-box or surrounding stone. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Bishops Ter. Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ii Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of pondirg, 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 ihspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM ,a' 360 Bishops Ter. Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 page. City(rown 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 y - 40 t5ins-3/13 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 360 Bishops Ter. Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 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: 12 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) ® 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 360 Bishops Ter. Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-2-15 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 T9 �LOCAIION N C) B TSTABLE b�.. h v S :P✓ SEWAGE - � �3 Vi I:AGF, rT G h S ASSE"OWS Nia:c&LOT .INSTALLER'S T�tAI�£&,PI�O1�Iv0 _ SSP'TFC T.A1>tK CAPACITY '�If�GS y LFACFIING°FACIIIT'd• -NO:-OFBS�M 3 bulLbER aR O�Y`t�IER AERA�TDATE _ �OA1I#'L1�iAICE'DATE: Separst�on l7istance Between tfie Ivlaxaianum Ad�astiO Groundwater Table to the Bottom of Le=tchIng Facility Feet Pnva#e watsr 3upplg►Well dud Leacluug Fly. ( any wails eats eat sacs qprrithi Z00 feet of De ng fac Edge`:of fE tand and'Lraclung#"aplky(lff any wetlattds exist withs4 3Q0 feet of teaehitg facility) rG S F t 1 ^r TIP K os R r r �� // TOWN OF BARNSTABLE LOCATION J rS`a�J -���G,c SEWAGE E 8CJ'e_4 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �i� / �c �/X�tlTi..c75ct� XPT 9W SEPTIC TANK CAPACITY 0,00 G'l-4- LEACHING FACILITY: 60 _ (size) l/X.29 oC2l NO,OF BEDROOMS BUILDER OR WNER &ILAV116a PERMITDATE: COMPLIANCE DATE: S�30.d 7 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 �. � � 0 � �. o� ca � s �o � �� � .. f y � uv No. 3 Tb Fee laU < P Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0ppYication for M!6pw6ar *p6tem Cow6truction Permit Application for a Permit to Construct( (Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Pazcel "'1 10 Installer'h Name,Addre ,and Tel No (J Designer's Name,Address and Tel.No. p � � �A C 7 -7,���� Type of Building: wel mg No.of Bedrooms Lot Size D sq.ft. Garbage Grinder( ) O er Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date 6 c/ Number of sheets Revision Date Title Size of Septic Tank OUO c Type of S.A.S. Y C ^h46rr I I k.1 Description of Soil 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 Certifi- cate of Compliance has been issued b i Bo o Signed Date l Application Approved by Date Application Disapproved for the following reasons Permit No. ?Do Date Issued 0 �/ lO o No. U ! �6 t a`" Fee > THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:l''� I _--� - Yes PUBLIC HEALTH IIVISION -TOWN'.OF B RN_$TABLES MASSACHUSETTS 01 ppfication for Mizpoar 6p5te-in Con!6truction Permit Application for a Permit to Construct( Repair,( )Upgrade( .,)Abandon( ) O Complete System ❑Individual Components i Location Address or J of No. / Owner's Name,Address and Tel.No. GU O�iS / J✓.�.0 e Assess is Ma /Parcel 07s,.2M , Installe//r��"))Names/Add re/��S ano 7el.No�f�/} Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size a U sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date _0 O y Number of sheets/ Revision Date Title � veLw/l �le.e,S .5 r � Size of Septic Tank 1000WIens Type of S.A.S. i' Description of Soil 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 Certifi- cate of Compliance has been issued} hi ardoT Hem. Signed G Date 7 Application Approved by Date $ �✓ Application Disapproved for the following reasons Permit No. �)04-3X6 Date Issued 8' ' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CER FY, that the On-s'te ew ge t osaltem Constructed ( ) Repaired (x) Upgraded( ) Abandoned( )by ©�� 7a 5 ' at 36a has been constru tedlin accordance with the provisions of Titl 5 and the for Disposal System Construction Permit No. VDU '3 g!? dated 13 U t'� IF Installer Designer The issuance of his perini,tshall not be construed as a guarantee that the sys em wi unction as desig� Date IX7l! . �lJ`r Inspector �.-/. �J No. Fee UU— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mizpoal *proem Cou5truction Permit Permission is hereby granted t Construct( `f Repair( )Upgrade( )Abandon( ) System located at 60 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:Constru do must be completed within three years of the date ofV* J7 �, j 1./ p� Date: 0 �3 ( Approved by IC-) 'c-S t TOWN OF BARNSTABLE f LOCATION J / /SS ,�^ �/ G,r SEWAGE VILLAG ASSESSOR'S MAP & LOT 20—D-7, INSTALLER'S NAME&PHONE NO. �ia� �1�z;�/ tliuL+/ SEPTIC TANK CAPACITY w � LEACHING FACII.ITY: (ty1�ri�l/� � Ly)- (size) //alx9 oC2` NO.OF BEDROOMS BUILDER OR WNERi kays/r4.9 PERMIT DATE: / COMPLIANCE DATE: $'-3 0—d 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 1100 feet o26ew aching facility) Feet Furriished by erl,lGac �33 sqb' o e �OJAI RONALD J. CADILLAC, PLS, RS Professional Land Surveyor Registered Sanitarian r _ Percolation Tests i Site Plans, Septic Designs Land Surveying& Consulting Phone or FAX. Toll Free: (508)775-9700 0 (800)520-5591 P.O. Box 258 West Yarmouth, MA 02673 4 r3i ti; r • FTHE Tp� Town of Barnstable '• j Regulatory Services • 9nxNnABLE. MA-R& Thomas F. Geiler, Director 9�A 1639. lEo �' Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 r¢ Office: 508-862-4644 Fax: 508-790-6304 w � Designer Certification Form Date: 8 127 � oz+ Designer: • J Cp -b ILL Address: _`r®, Zf2_ On was issued a permit to install a (date) (installer) I Q S tS � septic system at e '9 6 ,s � based on a design I drew, (address dated Z 104- V I certify that the septic system referenced above was installed substantially according to the design. I certify that the septic system referenced above was installed with changes but in accordance with State & Local Regulations. Revision or certified as-built by designer to follow. r rov p � w 1 x 3 •ZS ` 11 I Q� A'Ae.. w �,,�=Q. `� h''6"e 2 3 ' o s t1e, AVZoL L �, .ZA L> RONALD �5 - JAMES m -- CADLLLAC #1060 (Desig4,,k Signature) ( t e) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form �': ,. '> " "1 /� I �� � -� ---�+ /.� ✓ � Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM hereby certify that the engineered plan signed by me dated concerning the property located at 0-501 �- / jp� ✓et�4ce meets all of the ^ following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests at the site without a health agent present. • There is no increase inflow and/or change muse proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 170 B) G.W.Elevation 3/ +adjustment for high G.W. 4�4 _ 13(9 eJvA DIFFERENCE BETWEEN A and B , SIGNED : DATE: 2 D I NOTICE Based upon the above information;a repair permit will be issued for bedrooms maximum_ No additional bedrooms are authorized in the future without engineered septic system plans. J. gASeptic\percexemp.doc COMMONIATMJ i'II 01 M ASSA('i I USETFS EXECUTNE OFFICE ()l,' HJNVIPf.1NAII?NI'AL AFFf1IRS DEPARTMENT OF .i NViiMNAIE PAL PROTECTION FXLE® INSPECTION A1SESSoRS AMP NO a�6 PARCq NO. _ OFFICIAL INSPECTION FORM — NOT F OIZ VOLIJNTARY ASSESSMENT'S SUBSURFACE SEWAGE i)ISi'OSAi, SYSTEM FORM PART A CI_,RTIi iCATION Property Address: Q C) J- Owner's Name: AZ(J J Owner's Address: in Date of inspection: (� C) "o Name of Inspector: (please print) N Company Name: 1 c� o Mailing Address: N m t YVV ' Telephone Number: CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal :. "tent 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 maintenancr of'on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of•Title 5(310 CNIR 15.000). The system: Passes _ Conditionally Passcti Needs Further Fvaluatiim by the Local Approving Authority Fails Inspector's Signature: ®� Date: (� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Continents "'This retort only describes conditions at file tittle of incprrtiorr and under fire conditions of use at That tittle. This inspection does not address hots the system wilt perform in the future under the same or different conditions of use. r r Title 5 inspection Form 6/15/2000 rage 2 of^I I OFFICIAL INSPECTION FORM —NOT FOIL VOLUNTARY ASSES SMLNTS SUBSURFACE SEWAGE DISPOSM, SYS'i'I IVI INSPEC"PION I ORM PART /k CERTIFICAT1.0N (continue(i) Property Address':,.'�trO trfO� :�Oit r�J� ` `` �` 'j` �` `-' - Owner: M �,,�I7atc�bf'Inspcction: Inspection Summary: Check A,13,C,D or E/ALWAYS complete all of Section I) A. ` System Passes: 3 have not found any information which indicates that any of the tiiilure criteria described in 3 10 CMR 1-5 303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated ;ure indicated below. Comments: II. System Comditionnily Passes: One or more system components as described in the "(:'onditional repaired. The systcrn, upon co Pass"section need to be replaced or mpletion of the replacement or repair, as approved by the Board of l-Icalth, will pass. Answer yes, no or not determined (Y,N,ND) in the for file following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank (\vhelher 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 I Icalth. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year duc to broken or obstructed pipc(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)arc replaced obstruction is removed ND explain: w Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOIL VOLUNTARY ASSESSMENTS SUI3SUIZFACE SEWAGE DISPOSAi., S1'S'1'F,M iNSPI CTION FORM i'AR"T A Ci?RTIi'iCATION (c cmtinncd) Property Address: ?�= ��" Ill..7rk Owner: --------- Date of inspection: C. Further Evaluation is Required by, the Board of ileam, Conditions exist which require further evaluation by the Ite)ard of I lcalth in order to determine if the system is failing to protect public health, safety or the environment. I 1. Sr tem will pass unless Board of Hcalth determines in 11ccord:ucce 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: I _ Cesspool or privy is within 50 feet of a surfacc_%vaicr — Cesspool or privy is within 50 feet of a bordering vrt rtalecl ��etlancl or a salt marsh 2. System will fail unless the Board of 11ca1111 (an(I 1'u1)1ie- 1Vatcr Supplier, if any)determines that the System is functioning in a manner that protects the public Iccalth,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 supple. _ The system has a septic tank and SAS and the SAS is within a Zone i of a public water supply. The system has a septic tank and SAS and the SAS is «ithin 50 Icet 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 front a private water supply well**. Method used to detemine distance **phis system passes if the well water analysis, performed at a i EP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility,and the presence of ammonia nitrogen and nitrate nitrogen is rqual to or less than 5 pprn, provided that no other failure criteria are triggered. A copy of the analysis must he attached to this form. 3. Other: i f Page 4 of I i OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: (�( Owner: Date of inspection: ? !. 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 jZ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or IV hclogged SAS or cesspool Static liquid level in the distribution box-attove nutlet invert due to an overloaded or clogged SAS or r cesspool iY f Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2;lay flow —' Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number t/ of times pumped Any portion of the SAS, cesspool or privy Is below high ground water elevation. My portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water supply. l 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. VR_ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of a mnronia nitrogen and nitrate nitrogen is equal to or less than 5 pprn, provided that no other-failure criteria are triggered. A copy of the analysis must he attached to this form.] 'c 'No)The system fails. I have deterntincd 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 gild to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply — _ the systern 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— 1 WPA) or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section L- the systern is considered a significant threat, er answered "yes"in Section D above the large systern 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 systern owner should,contact the appropriate regional office of the Department. 4 Page 5 of I OFFICIAL INSPECTION FORM - NOT F Olt VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAI, SYST M INSPECTION FORM PA I ZT I C111?C'KI,IST Property Address: LC 'lll�C�2, Owner: T Date of Inspection: Check if the following have been done. You must indicate "yes"or "no" as to each of the following: Y^� No ✓`j _ Pumping information was provided b),file owner. nccupanl, or Board of I Icalth Were any of the system components punrpffl onr in the previous two weeks ? Has the system received normal (lows in the prcyimis two week period ? Have large volumes of water been introduced to the vstenr recently or as part of this inspection? Wcrc as built plans of the system obtained and c%amincd? (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 V _ Were all system components, excluding the SAS, locnted 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 constnrction, 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 i maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS)on the site has been detennincd based on: Yes no _/jZ Existing information. For example, a plan at the hoard of I Icalth. f/ _ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)] f 5 - j ]'age G of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9 r Owner: Date of Inspection: 04 FLOW CONDI'1'1ONS RIs'SIDGN7'IAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: I I o gpd x I/ of bc(Iroorns): 7 Number of current residents: Does residence have a garbage grinder(yes or ro :_ Is launi3ry on a separate sewage system (yes or no :_ [il .cs separate inspection rcyuiredJ Laundry system inspected (yes or no):_ Seasonal use: (yes or no): Water meter readings. if available (last 2 yearsrs u�rWLg)r())). --- (� I� Sump pump 0or no): —� 't� Orp" Last date of occupancy: 0 a ?'?1 000 11� COMMERCIAL/INDUSTRIAL Typc of establishment: Design flow(based on 310 CMR I f.203): Basis ofdesign flow(scats/persons/sq't,etc.): I lxl Grease trap present(yes or no):` — -- Industrial waste holding tank prescrit (yes or no): _ Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: --- Last date of occupancy/use: OTHER (describe): Pumping Records GENERAL INFORMATION � Sourcc of information: . .I,twlm an wf1u► R 31 '(� r611 , 100 Was systcm pumped as part of the inspection es or ro _ : If yes, volume pumped: gallons I lowywas quantity pumped determined? Reason for pumping: — TYY''E OF SYSTEM Septic tank,-h ex, soil aL-sorption systcm Single cesspool _Overflow cesspool _Privy Shared system (yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed if known):,nd soiree of inform i n: jj-+!.t� v Were sewage odors detected when arriving at the site(yes or o _ 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR R VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL !WSTFM INSPECTION FORM P A R'T' C SYSTEM INFORMATION (conhi ucd) Property Address: 3. JJ1� n Owner: Dale of Inspection: 1a BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC _ other 0•whin): _ Distance ffNit private water supply well or suction line: _ Comments(on condition of joints,venting, evidence of leakage, ctc.): SEPTIC TANK: /(locate on site plan) n Depth below grade: _ Material of construction: oncrctc_metal fiberglass polyethylene —other(explain) — — _ If tank is metal list age:—_ Is age confirmed by a Certificate of(.:ompliance(yes or no):_(attach a Copy of certificate) Dimensions: 9QQp Sludge depth: .. Distance from top of slu�ge 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 bottoiu of outlet tee or bafllc. I flow were dimensions detennined: M/15i(xp{,tnQ Comments(on pumping recommendations,Wet and outlet ter or bafTlc condition, structural integrity, liquid levels as related to outlet invert,evidence of.leakage, etc.): GREASE TRAP:_(locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet (cc or hafTle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SENVAGI: DISPOSAL SYS'I'I.?M INSPECTION FORM PART C S YSTENI INFORMATION(continue(l) Property Address: Owner: Date of Inspection: " (� TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete Inctal_ film-glass polvethylene __other(explain): Dimensions_ - ---- Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarnr level: Alarm in working order(yes or no): Date of last pumping: -- Commonta (condition of nlnrm and nont switeim,, etc.): DISTRIBUTION I3OX: (if present must be opcnc(l)(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 or no): Alanns in working order(yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Y lPage y of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SENVAGE DISPOSAI, SVSTE111 INSPECTION FORM PART C SYSTEM INFORMATION (conrtinuc(l) Property-Address: n _ Owner: At 914 j I ? Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): _,/ (locale on site plan, excavation not required) If SAS not located explain why:. Typq i ,/ leaching pits, number: (� 6 Ieaching chambers, number: leaching galleries, number: Ieaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool, number: _ innovative/alternative system T}I)c/name of technolohv _ Comments (note condition of soil, signs of hydraulic failure, Ir vcl of ponding, damp soil, condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of iw j,cciion)(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 or no): Comments(note condition of soil, signs of hydraulic failure, Icvrl 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, Irvcl ofponding, condition of vegetation, etc.): U Page 10 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYS"ITF,M INSPECTION FORM PAIZT C SYSTEM INFORMATION (cmitinuc(l) Property Address: -yr Owner: Date of Inspection: 1 0'2 v!1 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including tic-, to at least two permanent reference landmarks benchmarks. Locate all wells witl ' I rks or . nn 10� feet. [.,ocate where mhlic water s i i • I t pl I} enters the building. 3 UO z a a� 3 3ti ,n Pagel 1 of I I OFFICIAL INSPECTION FORM --- NOT FOR VOl,I!N'1'AIZY ASSESSNII,N'I'S SUBSURFACE SEWAGE DISPOSAL Sl•,`•1'FM INSPECTION FORNIT PART (' SYSTEM INFORMA•1'll ►N (ccmtinuc(l) 1'rope rtN Address: 'Jfa0 Owner: Date of Inspection: 610 31QZ_ srrt: EXAM slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the hiph g,wind water elcvatinn: Obtained from system design plans on record - If checked, 1.1atc of design Flan reviewed: Observed site(abutting property/observation hole within I () fc.0 of SAS) Checked with local Board of Health-explain: _ Checked with local excavators, installers- (attach docurnent.it ion) Accessed USGS database-explain: 1 You must de cribe h w yqu establish_e� the high Kround «ate cic rlion: I1 ALWAYS DIG SAFE PRIOR TO CONSTRUCTION--UTILITY LOCATIONS SHOWN INCOMPLETE. JOB NO. B04-13 m NOTES Primavera.dwg ;es a n .fey° p 1. LOCUS IS A.M. 250, PARCEL 75. poth 2. ELEVATIONS SHOWN ARE ASSIGNED. c`nv 3. LOCUS IS IN FLOOD ZONE C ON FIRM DATED AUGUST 19, 1985. 0 Z 4. ALL PIPES TO BE 4" SCH 40, AND PITCHED AT 1/4" PER FOOT. (UNLESS NOTED) v Q BOARD OF HEALTH REQUIRES R.J. CADILLAC TO 5. MUNICIPAL WATER IS AVAILABLE. LOTS WITHIN 100' ARE ON TOWN WATER. a- INSPECT PRIOR TO BACKFILL. 6. COMPONENTS TO BE AASHTO H-10, UNLESS NOTED. 7. INLET TEE TO PROJECT DOWN 13", OUTLET TEE DOWN 14". o y v 8. IF TWO OR MORE LINES, WATER TEST D-BOX FOR EQUAL FLOW J D-BOX EXIT PIPES TO BE LEVEL FOR FIRST TWO FEET. R� Za 9. DEPTH OF COMPONENTS NOT TO EXCEED 3', OR VENTING MUST BE PROVIDED. NOT TO COVERS: BUILD UP COVERS TO 6" BELOW GRADE--1 ON D-BOX, 1 ON LEACHING SCALE 10. STONE TO BE DOUBLE WASHED 3/4 TO 1 1/2" WITH 2" MIN. 1/8 TO 1/2" PEA STONE ON TOP. LOCATION MAP 11. IF UNSUITABLE SOILS, OR SOILS DIFFERING FROM THE SOIL LOG ARE FOUND, CONTACT THE BOARD OF HEALTH, OR R.J. CADILLAC. N/F 12. IF AN OVERDIG IS CALLED FOR BELOW, FILL MATERIAL FOR 5' AROUND AND UNDER LEACHING IS TO BE CLEAN GRANULAR SAND MEETING SPECIFICATIONS OF 310 CMR 15.255(3). TEST HOLE 1 JENNINGS 13. PUMP AND FILL ANY EXISTING CESSPOOLS. REMOVE ANY CLOGGED SOIL, BLOCK, AND STONE IN LEACH AREA, AND DISPOSE OF AS DIRECTED BY HEALTH AGENT. DEPTH (inches) ELEV.(feet) N/F 14. ALL CONSTRUCTION TO MEET TITLE 5 AND LOCAL REGULATIONS. 0 31.6 A/E layer 10yr 3/ CAMPOS TEST HOLE DATE: July 30, 2004 6" loamy sand N 770620- W BENCH MARK-TOP REAR CENTER PERFORMED BY: Ron Cadillac, Soil Evaluator SEPTIC TANK = 31.56 ASSIGNED WITNESSED BY: B layer 10yr 5/8 1634�• PERC RATE: <2'-00"/inch (C layer) sandy loam NO GRADE CHANGE 33.1 SOIL SURVEY(1993): Eastchop loamy fine sand 36" GEOLOGIC MAP(1986): Barnstable plain deposits 28.6 LOT 12 PROPOSED Top Foundation � Cl layer 2.5y 6/6 Invert 30.15 54"0 loamy med. sand Use Gas Baffle 4 HI-CAP 20% ravel 2 0 7 9 0± S. �. 4 Proposed Invert 28.13 INFILTRATORS 90" 9 24.1 30., Proposed 28.6 732A 3 31 8 o S=1 3/4"/ftt Top Peastone C2 layer 2.5y 6/4 \ a Existing 4" Inspection med. coarse sand 3 _ \ 6 �D Port N \ I 1000 Gal. ,4 o no water o o ��14 W I 24" 137" 20.2 N N BENCH MARK-TOP OF WOOD STAKE SET FLUSH= 30.97 ASSIGNED a "131,2 I Invert 28.30 Invert 28.1 N (57'-9" OFF S.W. CORN. HOUSE) L 3L6 1 32,0 CO Nc �3 ,2 6" Stone or compact Proposed Proposed I 5.9' 26.1 -[ 32,: Cv 2,4 32.0 O�'�I�F I �12' I I N I 1, I Bottom C 31,7 � Bottom TH1=20.2 N/F A7 `m_ ASHE = 2.0 = �c DESIGN DATA 0 to 32 2 wf7 x 30,y BEDROOMS: 3 / 201 / / wv 1.3 GARBAGE GRINDER: No LEACH AREA REQUIRED CAPACITY: 330 GPD 31.8 EXISTING SEPTIC TANK: 1000 GAL. USE 4 HIGH CAPACITY INFILTRATORS WITH L6 20 ��, 32.0 BOTTOM LEACHING AREA: 319 SF APPROX. 4' OF STONE ON SIDES AND 2' o OF STONE ON THE ENDS, AND 14" OF [(29SIDE LEACHING AREA: 160 SF STONE UNDER TO MAKE A 29' LONG BY 31.1 \31,8 [2(11 + 29) X 2 DEEP)] 11' BY 2' DEEP LEACH AREA. DESIGN CAPACITY: 354 GPD [(319 SF + 160 SF) X .74 GPD/SF] a '�F �� � C? N .- TH 1 1,6 c` to w c� 31 a 9. s7 F 20" E \ ' 30,2, - F � 0 1, LEACH AREA CAN BE FIELD ADJUSTED IN N/F THIS AREA TO AVOID TREES OR BUSHES. BOISSONNEAULT n,.r BENCH MARK--TOP OF MAG. m NAIL= 30.00 ASSIGNED �►1 SITE PLAN FOR THIS PLAN A VALID COPY ONLY IF 11 BEARS ESTATE OF VERNONIKA M . RUTKAUSKAS AN ORIGINALL RED STAMP AND SIGNATURE. LEGEND ��A OF MASS ��SNOFNr'ASSgO LOT 129 360 BISHOPS TERRACE, HYYANNIS, MA R AL ti L yGs AUGUST 2, 2004 SCALE: 1 "=20' TH 1 TEST HOLE LOCATION, NUMBER J E o E , W WATER LINE MARKINGS 5779�� E OVERHEAD ELECTRIC WIRES (IF SHOWN) # 106o p #3 G- GAS LINE MARKINGS c�S-T �gtin�ss�°oe x 9.5 X g,7 EXISTING & PROPOSED ELEVATIONS ('X' MARKS POINT) SgNirnR` RONALD J. CADILLAC, PLS, RS EXISTING CONTOUR ! IQ PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN _g PROPOSED CONTOUR P.O. BOX 258 UTILITY POLE (IF SHOWN) WEST YARMOUTH, MA 02673 - FENCE (IF SHOWN, NOT ALL SHOWN) (508) 775-9700 HEALTH AGENT APPROVAL DATE PAGE 1 OF 1 C 2004 BY R.J. CADILLAC