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HomeMy WebLinkAbout0105 DUNN'S POND ROAD - Health 1'OS Dunn':_; Po-ad", Gad I Ilyannis t I G390'6 � r ;I a � I' I I I i i i f Commonwealth of Massachusetts _ 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Sy 105 Dunns Pond Road Property Address -- Manuel Ribiero Owner. Owner's Name information is required for every. y Hyannis MA 02601 12/21/12 page. City/Town - State Zip Code.- Date of Inspection - Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. .... Important:When A. General Information filling out forms on the computer, use only the tab : 1. Inspector: lY key to move your cursor-do not. . Ricky Wright use the return: key. Name of Inspector B & B Excavation,Inc. Company Name 14 Teaberry Lane Company Address Forestdale MA: : :. .02644 City/I own State Zip Code 508-477-0653 S14595 Telephone Number License.Number a B. Certification =� certify that I have personally inspected the sewage disposal system at this address and that the,,., information reported below is true, accurate and complete as of the time of the ?spectiom The inspection was performed based on my training and experience.in the proper function and rr�aintenano�of onsite sewage disposal systems. I am a DEP approved system inspector pursuant to Section, 5.340of Title 5(310 CMR 15000). The system: -a 0 Passes. Conditionally Passes Falls ... . ElEl Needs Further Evaluation by the Local Approving Authority 12/26/12 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•11110:: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 105 Dunns Pond Road Property Address Manuel Ribiero Owner Owner's Name information is required for every Hyannis MA 02601 12/21/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 105 Dunns Pond Road Property Address Manuel Ribiero Owner Owner's Name information is required for every Hyannis MA 02601 12/21/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 105 Dunns Pond Road Property Address Manuel Ribiero Owner- Owner's Name information is required for every Hyannis MA 02601 12/21/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 % day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 105 Dunns Pond Road Property Address Manuel Ribiero Owner Owner's Name information is required for every Hyannis MA 02601 12/21/12 page. CitylTown 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. 6 ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 105 Dunns Pond Road Property Address:. ... Manuel Ribiero Owner: Owner's Name information is required for every Hyannis MA 02601 12/21/12 .. page. Cltyrrown - 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? El Z 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 EJ ® this inspection? ED . Were as built.plans of the:system obtained and examined?(If they:were not. available note as N/A) ® ❑ Was the.facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑. Were all system components, excluding the SAS, located on site?. ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with El ® 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. El ® Determined in the field(if any of the failure criteria related to Part C is at issue :approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential.Flow Conditions: _ . Number:of bedrooms(design.) 4 . ... Number of bedrooms (actual): 4 DESIGN flow based.on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•11/10:.: 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 ^M 105 Dunns Pond Road Property Address Manuel Ribiero Owner Owner's Name information is required for every Hyannis MA 02601 12/21/12 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? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑.Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail Sump pump? i ❑ Yes ® No Last date of occupancy: August 2012 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 W 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 ;M 105 Dunns Pond Road Property Address Manuel Ribiero Owner Owner's Name information is required for every Hyannis MA 02601 12/21/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy { ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 105 Dunns Pond Road Property Address Manuel Ribero Owner Owner's Name information is required for every Hyannis MA 02601 12/21/12 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: 2010 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20 feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 2 1/2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No Dimensions: 1500 gal 611 Sludge depth: 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 105 Dunns Pond Road Property Address Manuel Ribiero Owner Owner's Name information is required for every Hyannis MA 02601 12/21/12 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 30" Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound. No sign of back-up. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 9 Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10. Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 105 Dunns Pond Road Property Address Manuel Ribiero Owner Owner's Name information is required for every Hyannis MA 02601 12/21/12 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 105 Dunns Pond Road Property Address Manuel Ribiero Owner Owner's Name information is required for every Hyannis MA 02601 12/21/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 105 Dunns Pond Road Property Address Manuel Ribiero. Owner Owner's Name information is required for every Hyannis MA 02601 12/21/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: (9)arc 3050 ❑ 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.): At time of inspection leaching is dry and in working condition. No sign of hydraulic failure Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 105 Dunns Pond Road Property Address Manuel Ribiero Owner Owner's Name information is required for every Hyannis MA 02601 12/21/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f - Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I Dunns Pond Road Property Address Manuel Ribiero Owner Owners Name information ie required for every Hyannis MA 02601 12/21/12 page. Citylrown 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. Locafe where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below El drawing attached separately A 8 a 33►5 �t ( A2= 40, �14.9 „ �33 : 38'6 " A*4 7� '2 15ins•11/10 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 105 Dunns Pond Road Property Address Manuel Ribiero Owner Owner's Name information is required for every Hyannis MA 02601 12/21/12 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: >10' 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: 10/29/10 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: 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 r Commonwealth of Massachusetts L u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 105 Dunns Pond Road Property Address Manuel Ribiero Owner Owner's Name information is required for every Hyannis MA 02601 12/21/12 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 l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION `Q Z /4/d �C� SEWAGE# (;.0(D- 3� VILLAGE 11�Yi44h/ S ASSESSOR'S MAP&PARCEL-2 4 9, /d l INSTALLER'S NAME&PHONE NO. gyvsr—,eG l w dPhcf Z o/(.) SEPTIC TANK CAPACITY (J LEACHING FACILITY:(type) a,*d{i S (size) 7 7,0VX 1Z4_'Y sc'Z NO.OF BEDROOMS yy OWNER V" e� PERMIT DATE: /®- L 9. /0 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet 1 Private Water.Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) IL)IA Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi c 1. ) /" Feet FURNISHED BY i i 0 Q� O cC Cep ( f4 — c � No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0[ppYtcatiou for Btgpo!5a16pgtem Cou5tructtou permit Application for a Permit to Construct( ) Repair V")' Upgrade( ) Abandon( ) PrComplete System ❑Individual Components Location Address or Lot No. 1 O S t)u✓,i 2 Jj Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 2_ Installer's Name,Address,and Tel.No. �j o v$ ( Designer's Name,Address and Tel.No. 2 6'k to b q 0 k/ SA-wtd i—tC k R3 3 2427 Type of Building: / Dwelling No. of Bedrooms Lot Size 6 9�.V' sq. ft. Garbage Grinder ( ) Other Type of Building S1 e-is l2 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) � gpd Design flow provided 0�2— gpd Plan Date /O —/o ^ / O Number of sheets Revi Zon Date /t dA✓—e Title Size of Septic Tank l 3'0d Type of S.A.S. �l ,74,, CAA,h �P�P vr� o�✓� Description of Soil Ste' 10 r A. I Nature of Repairs or Alterations(Answer when applicable) P-e P(,a,—,e Ge ct CQS S esu l S Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He lth. S gned Date Application Approved b Date f ,4411,11 Q Application Disapproved by: Date for the following reasons Permit No. Date Issued =A No. Fee r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes - t 01pplication f or--0igpo!9af *_ Poem Con!5tructiou Permit s Application for a Permit to Construct( ) Repair(V� Upgrade('') Abandon( ) Complete System El Individual Components Location Address or Lot No. (C3 S L)u^6 S'f d Owner's Name,Address,and Tel.No. Assessor's Map/Parcel "Z-4 cl' /a Installer's Name,Address,and Tel.No. .e Designer's Name,Address and Tel.No. 3o)e M"i Sa,,dwfr-k P33 2r77 iType of Building: / Dwelling No.of Bedrooms Lot Size - 6 YAc✓Ef sq.ft. Garbage Grinder ( ) Other Type of Building Sins (Ae 44*ik,'/� No.of Persons Showers( ) Cafeteria( ) Other Fixtures � Design Flow(min.required) `7 6 gpd Design flow provided 2-- gpd Plan Date U . /o " / 4 Number of sheets Revi on Date /I div-2 t- Title Size of Septic Tank /5�?C) Type of S.A.S. /1/4S4 C_ CA'a"'r &,-.r 70— C Description of Soil SE' E to/,A /1 Nature of Repairs or Alterations(Answer when applicable) f _Cl P(GIG e { Ge CPS S Q do 1 S r i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. S"gned Date ( 6-Zh�B, Application Approved b} Date /)I pt 'l Q Application Disapproved by: Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (�) Upgraded ( ) Abandoned( )by 10 c./S Fe (Cl 1._�/All r4-,41,4 S�2 C at I!1 S n n 1 S has been constructed in accordance rL with the provisions of Title 5 and the for 2 Disposal System Construction Permit No. rho/G`��� dated �4/erp �/� Installer ,6,,S-� t ( 6 ��"4- Ix r Designer (D8C 'ENV / #bedrooms '-(' Approved des gp flow Y Z- gpd The issuance of this e it shall not be construed as a guarantee that the system will funnctio as designe . Date, ��111 11� Inspector `/� 1�✓. No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS wi!5po!5a[ *p5tem Construction Permit I . Permission is hereby granted to Construct ( ) Repair (P ") Upgrade ( ) Abandon ( ) System located at ,/©j`// b L"I✓ S f'a led fTLi�4�✓t i 5 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction Tnust be gompleted within three years of the dat(e of this p it. Date Approved b i Town of BarnstAble y� Regulatory Services Thomas F. Geiler,Director » �ARIYSTASLE, + " a Public Health Division 9. �0. rFo � Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644- Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: .'� . AWbPOI1 ' � Installer: Address: . 64:5t 5CUA&k�n Address: GreP & C 0. O_29''Za�_� was issued a permit to install 11 a (date) (installer septic system at 10 ! 'Winl� (address) based on a design drawn lo.y ` '�"� �% V"�C �✓ dated "( b ! O -Z 6 / a (designer) :certify that the septic system referenced above was installed substaut7lly according'to `:lie design, which may include minor approved changes such as late relocation T the ilh5b ibution box and/or septic tank. _ I certify that the septic system:referenced above was installed vnth'.malor changes (t,;e, greater tha Y 0' lateral relocation' of the SAS or--any vertical.relocation of any compont of the.septisystem)but in accordance with State&LocalfZegtilatons. Plan revisozk or certified as-boat by designer t$`foliow. 3 (Installer's Signature) n 967AS.ON m A sgNltAa�P� (D er s Signature) (Affix e igner',s Sta:op.Here) PLEASE R:E7E'URN TO WNSTA LE PUBLIC.HEALTH.DIVISION.. "CERTII+Inc TE OF.: CO1VJ��,IANCE I,L :N®T E SSUED UNTII "BOTH :3"Dl[S{FORIGI BUIEL QW ARE RECEIVED RY 1lE.-R. I STABLE Pt WCNE;A,L1'�[ THANK YOV: y ' • ze Q:R lealWepticlDesigner Certifica,on'F�m, 1 1114S01,v Town of BarnstableP 4t ?o Department of Regulatory Services Public Health Division M Dater �. 2° tbgy� ",b� 200 Main Street,Hyannis MA702601 Arfo Met , Date Scheduled 7 Tirrie' v P Fee Pd. Soil Suitability ssessrnent for{Sewa "e pisposal Performed By: Witncssed By ' kx f �� LOCATION & GENERAL INFORMATION / Location Address -�Q !�u�n f`PC/ j C owner's NameR�•�j p,:K 6 Address Assessor's Map/Parcel: ( I Engineer's Name 08C e?v[i�P NEW CONSTRUCTION REPAIR Telephone# F2 3 77 Land Use Slopes( ) 1/1' " ` Surface Stones Distances from: Open Water Body --ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line __— ft Other ft SKETCH: (Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands in proximity to holes) 47 Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping*om Pit Pace Estimated Seasonal High Groundwater DETERMINATI Method Used: ON FOR SEASONAL HIGH WATER TABLE Depth Observed standing in obs.hole: Depth to weeping from side of obs.hold: in, Depth to Soll mottles:GrdundwaterAdjust in, Ln, Index Well# Reading Date: Index Well level ft. -- AdJ,factor �4 ment AdJ,Groundwater7xvel Observation /- �1 PERCOLATION TEST btite Hole# V Time at 9" Depth of Pero t --,^- Time at 6" Start Pre-soak Time @ Time(9"-6") — End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional'Testing Needed(Y/N) Original: Public Hearth Division Observation Hole Data To Be Completed on Back----------_ ***If percolation test is to b'e conducted within 100' of wetland, you must first notify the Barnstable Conservation Division at least one (1) week prior to beginning. Q:1�EPTIC\PER C FO RM.D OC DEEP-OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Surface(in.) Soil Color Soil Other (USDA) (Munsell) Mottling (Structure,Stones;Boulders. on i to c °h ravel L5Jof6 W.Sim Io DEEP OBSERVATION HOLE LOG Hole F# R- Surface Depth from Soil Horizon Soil Texture(in.) Soil Color • _ Soil - Other a (USDA) (Munsell) Mottling (Structure,Stones,Boulders, C nsiste c % ravel) DEEP OBSERVATION HOLE LOG Hole# Depth from 'Soil Horizon Soil Texture Soil Color Soil Surface(in.) Other - t (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Co i to 'Y Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Sol] Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Co si to 1 Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No! Yes Depth of Naturally Occurring Pervious Material .Does at least four feet of naturally occurring perviQus.4A0eLnal exist in all areas.observed throughout the area proposed for the soil absorption system? i+ If not, what is the depth of natura ly occurring pery ous material?!/ F y= Certification - I certify that on �� (date)I have passed the soil evaluator examination approved by the Department of.Enviro1mcrital Protection and that the above analysis was performed by me consistent with . the required trainin exper ' e d xperience described in 310 CMR 15,017 Signat Date O) Q:\HFTlC\PERCFORM.DOC �tHE T Town of Barnstable "'"astable Regulatory Services Department OA RNS't'A[31.E, MASS. a 1: Public Health Division 'OTf A.t a��� \_ - 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70083230000251782718 6/24/2010 O [Ply coo Michael Villam 105 Dunn's Pond Road Hyannis, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 105 Dunn's Pond Road, Hyannis MA was last inspected on May 24, 2010, by Marl Polselli, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Any portion of the SAS, cesspool, or privy below high groundwater elevation. You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification. Failure to repair/replace the,septic system within the deadline period wi11 result in future enforcement action. _ ORDER OF T BO OF HEALTH T omas McKean, R.S., CHO Agent of the Board of Health r - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for/Voluntary Assessments 11�5 0414h1 Property Address ��/0G,a !�' / 1/ll� �, Owner Owner's Name l information is �7yAHh�s 0a60/ required for every page. City/Town State Zip Code Date Inspe tion 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 I l forms on the computer,use 1. Inspector: only the tab key to move your q�/� /)OISPi ll/ cursor-do not Name of Inspector use the return key. �� Vl tray I I Company Nam, na �O-- /-) Company Address—11 rl/� /4,; City/Town State Zip Code 'd Telephone Nu r 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 CM 15.000). The system: ❑ Passes ❑ Conditionally Passes .Fails .. I ❑ Needs Further Evaluation by the Local Approving Authority xc"�, �t aY Inspect is Signature Dateyy 4F' 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. 1V 15ins°09/08 Title 5 Official Inspection Form:Subsurface Sewage Dis sal System-Page 1 of 17 i l 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 5 aY/,v required for 4: hJi If every page. City/Town State Zip Code Date" f Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System r 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): r 1 t5ins-09r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments /0S �u Nl9s /'io r►.1 /C Property Address / Owner Owner's Name !U information is N60/ S o2 required for / ��^ kip?'! AY f In every page. City(Town State Zip Code Date sp ction B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ 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 I ystem will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): r 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•09/08 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspectionform Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address /� 1/ / Owner Owner's Name information is q vl N 1 0�b0l ���=Yhv required for State Zip Code Date of Inspection every page. City/Town 011- B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: , *' This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Fail rekiteria 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 El Static liquid level in the distribution box above outlet invert due to an overloaded r clogged SAS or cesspool ❑ , �/ Liquid depth in cesspool is less than 6" below invert or available volume is less u than Yz day flow 15ins-09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /oS �uhhs �h Cj M Property Address Owner Owner's Name information is �/ O�6c�/ 5 required for every page. City/Town State Zip Code Date— of p ctlon B. Certification (cont.) Yes No ❑ E 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. ❑ L7 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. L� ❑ 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. l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 5 of 17 _ Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments oS h s 'p h ,Z ✓� M Property Address �///4 Owner Owner's Name information is a N H fs /�i� OoZ 6 0 / 42 4 y� required for State Zip Code Date of Inspection every page. City/Town .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? ❑ Z--,Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ��❑ Was the site inspected for signs of break out? �/❑ Were all system components, excluding the SAS, located'on site? ❑/ [J 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? l- Was the facility owner(and occupants if different from owner) provided with L� ❑ 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: 0/ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part-6 is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 C'MR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•09108 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 /0 al-4 ki$4 J, Property Address // v1fl� t7 , Owner Owners Name information is G �s QoZ(,0 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Sr H5 le- cess'/0,0a i Number of current residents: Does residence have a garbage grinder? ❑ Yes 0_<0 Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes [9- No Laundry system inspected? ❑ Yes [�No Seasonaluse? ❑ Yes o Water meter readings, if available (last 2 years usage (gpd)): Detail: Sum pump? ❑ Yes PP P Last date of occupancy: Date Commercial/Industrial Flow,Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present?. ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments zos C/ • Property Address �/•/ )� �/ ' Owner Owner's Name ` /- information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ eptic tank, distribution box, soil absorption system Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9N Property Address V/l N , . Owner Owner's Name information is Ac', r / 7 C2a60 a I lorequired forernvt N j every page. CityfTown State Zip Code Date o Inspect on D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 0 Were sewage odors detected when arriving at the site? ❑ Yes [y, o Building Sewer(locate on site plan): iJ Depth below grade: feet �J Zerial ofstruction: ast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well,or suction line: feet l Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•09r08 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 4 C/ Property Address �Zc 0 t Owner Owner's Name information is /!�� ey 6 0/ required for every page. City/Town State Zip Code Date f Inspec ion D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence.of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: El El ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is H G H h required for every page. City/Town oil State Zip Code Date of nspection 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 t Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Iz/f . Owner Owner's Name information is H required for State Zip Code Date of Inspection every page. City/Town C71- D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 'Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): t Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 24 U. Property Address /117 Owner Owner's Name information is required for every page. City/Town State Zip Code Date of nspecti n D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ eaching galleries number: /o X 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.): -PSI o o / o t.,/ J I Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration . I� Depth —top of liquid to inlet invert Depth of solids layer ...e Depth of scum layer Dimensions of cesspool / /9l i� Materials of construction Indication of groundwater inflow ❑ Yes No t5ins•09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13of 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 State Zip Code Date ot Inspection every page. City/Town 417 D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments J �c /0� tiN�'1 j or Property Address ( f (G �ll Owner Owner's Name 14,,information is /o required for C`H N`f every page. City/Town State Zip Code Date of nspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two pe manent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate :7and-skethin e p 'c water supply enters the building. Check one of the boxes below: c the area below ❑ drawing attached separately 9 o, 15ins-09108 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 gd Property Address Owner Owner's Name I _ 0;160�1 S a Y/� information is a,h h 11 f required for State Zip Code Date of Inspection every page: City/Town D. System Informatiorl (cont.) Site Exam: "1—�r 0 �0 Check Sloe ICOA 3Q. ❑ -Surface water ❑ Check cellar ❑ Shallow wells jee 1J L, _ 6 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: 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) f ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: ------------- cr/ SS 00 d �_e 0 oZ $ e ell S C� Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection form:Subsurface Sewage oisposat System-Page 16 of 17 l5ins•09108 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments y / Property Address -//,•� Owner Owner's Name information is / VIPo� Nh I required for ate of Inspection every page. City/Town 47- State Zip Code DI E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ET"System Information— Estimated depth to high groundwater Sketch of Sewage Disposal System either,drawn on page 15 or attached in separate file _ r 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i 1 ASSESSORS MAP : 'z�g TEST. HOLE LOGS _ -. _ ---__ NOTES: PARCEL: /O/ FLOOD ZONE: 1t16/ -plPL IC,- }o SOIL EVALUATOR : U - - -- -- WITNESS : Iq�l 1) The installation shall comply with Title V and Town of Barnstable Board of REFERENCE: " -- DATE: DI I Health Regulations: PERCOLATION(RATE -� Z ►►�1 I 2) The installer shall verify the location of utilities, sewer inverts and septic 1n� 5 components prior to installation and settingbase elevations. \oe "' 3 All gravity septic piping to be 4 inch Sch 0 PVC at 1/8"g y p p p g per foot. The first two feet out of the d-box to the leaching shall be level. WEB— 11411,-1 a I,p Ib 4) This plan is not to be utilized for property line determination nor any other Qll 3 'J(I purpose other than the proposed system installation. 5 S) All septic components must meet Title V specifications. 6) Parking shall not be constructed over H 10 septic components. ,,. 7) The property is bounded by property corners and property lines. ' „;l � 3 P Y P P Y LOCATION MAP 8) The property owner shall review design considerations to approve of total . CD design flow and number of bedrooms to be considered for design. Receipt c 6� of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material r Title V abandonment procedures.`Those within per p the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per Title V specs. ' �T 1 �✓ 10)System components to be 10 feet from water line. Sewer lines crossing the - 1 ' � ✓', �L 1rA4P-- - water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. The proposed SAS is being'installed below the water`service SEPT I C ,°SYSATEM DESIGN . . g line. The line is to be sleeved as aforementioned and maintained in place. I►Ih� o I 11) If a garbage grinder exists it is to be removed and is the responsibility of the 1 FLOW ST. MAT�. ,i �. owner to ensure such. 12)The installer is to take caution in excavation around the gas line if such I BEDROOMS AT IIO GAL/DAY/BEDROOM - `ICE GAL/DAY exists. 13 The installer shall verify the location, quantity antity and elevation of the sewer I SEPTIC TANK lines exiting the dwelling prior to the installation. GAUDAY x 2 DAYS - ��GAL �i USE 1 ) GALLON SEPTIC TANK L �1r� � A 'O p SOIL ABS;►RPTION SYSTEM - - � 6 D roc, ! tom ,I'- 2 p� awl ,�P�,c M.,� � s N OF ; r ,.. S< .�`:. itEA: L -t^ l ;vs. G i! + 7 :> 1 ! n W' BOT i OM AREA: 07c v- 0-7 - NCP, ' C SYSTEM SECTION 41 _ b w b? or- rwoynF1 - j . oe F70 Q /'1 I b *b (� a. 0. � GAL _ o o d o p v o o q- SEPT I C TANK J C SITE AND SEWAGE PLAN LOCATION : I0 1 �►��r^I ` {�Dti1'� ITS PREPARED FOR : ,6x)f:JF,1EUD C:�-E�L M FbC CALE: I a DAV I D B . MASON) S DATE: its id �� z DBC ENVIRONMENTAL DESIGNS Z EAST SANDWICH . MA W DATE HEALTH AGENT z ( 508 ) 833- 2I77