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HomeMy WebLinkAbout0043 ERIN LANE - Health '43 Erin Lane 1 IHyannis �A = 291 017 II i li i R Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -� 43 Erin Ln. t Property Address * .i Pat Devine Owner Owner's Nam Information Is 9 � required for every �anniS ✓ MA 02601 8/2/2019 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 q, Inspector Information filling out forms N on the computer, use only the tab Douglas Brown key to move your Name of Inspector cursor not return use the ret Cape Cod Septic Services Inc urn key. Company Name 350 Main Sty rah Company Address - West Yarmouth MA 02673 Citylrown State--- Zip Code 508-775-2825 S15016 Telephone Number License Number B. Certification., I certify that: I am a DEP approved system Inspector In full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-cite sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes' 3, ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Ins ' or's 3igna ure = _ 8/2/2019 Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board_ of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes p Y es conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform In the future under the same or different conditions of use. t5insp.doc•rev.7/2812018 Title S Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts —, Title 5 Official- Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Erin Ln. Property Address Pat Devine Owner Owner's Name information is Hyannis required for every y MA 02601 8/2/2019 page. Cltyrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® [ 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 in working condition. ' 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available: ❑ Y ❑ ;N ❑ ND (Explain below): t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts -- , Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 43 Erin Ln. Property Address Pat Devine Owner Owner's Name information is required for every Hyannis MA 02601 8/2/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due . to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipes) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 43 Erin Ln.. Property Address Pat Devine Owner Owner's Name information is required for every Hyannis MA 02601 8/2/2019 page. Cityrl'own State Zip Code Date of inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. . ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: ' v 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections:a 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 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments J� 43 Erin Ln. Property Address Pat Devine Owner Owner's Name information is Hyannis MA 02601 8/2/2019 required for every State Zip Code Date of Inspection page. City/Town C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below.invert or available volume is less than Y2 day flow ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Cj ® 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 El 0 tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the `questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form , ' Ise Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Erin Ln. Property Address Pat Devine Owner Owner's Name information is required for every Hyannis MA 02601 8/2/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant" threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes 'No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Cl ® 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) Z ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 L - Commonwealth of Massachusetts Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 43 Erin Ln. ' Property Address Pat Devine Owner Owner's Name information is Hyannis MA 02601 8/2/2019 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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): 440pd 110gpd Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry.on a separate sewage system? (Include laundry system.inspection Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 2017=70gpd2018=152gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknownDate t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Erin Ln. Property Address Pat Devine Owner Owner's Name information is required for every. Hyannis MA 02601 8/2/2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Erin Ln. Property Address Pat Devine Owner Owner's Name information is required for every Hyannis MA 02601 8/2/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ _ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2003 Per BOH Records. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 20"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line was checked with sewer camera and found to be clean properly pitched with no sign of root intrusion. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Erin Ln. Property Address Pat Devine Owner Owner's Name information is Hyannis MA 02601 8/2/2019 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) 6. Septic Tank(locate on site plan): 10„ 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 1500Ga1 Dimensions: 3-41' Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 1-2" 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? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Ga1 tank in good condition. PVC tees in place and clean. Tank at normal operating level. Covers 12" below grade. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Erin Ln. u- Property Address Pat Devine Owner Owner's Name information is required for every Hyannis MA 02601 8/2/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): . 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: , ❑concrete ❑ metal ❑fiberglass ❑ polyethylene 0 other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts i Title 5 Official Inspection Form Flo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Erin Ln. �u Property Address Pat Devine Owner Owner's Name information is required for every Hyannis _ MA 02601 8/2/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 DB-3 with 1 line in and 1 line out i9n good condition. Box is clean and level with minimal solids carryover. No sign of overloading or hydraulic failure. Cover 20" below grade. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 43 Erin Ln. " Property Address Pat Devine Owner Owner's Name information is required for every Hyannis MA 02601 8/2/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: El Teaching pits. number: ® leaching chambers number: 5-3050 Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 13 of 18 Commonwealth of Massachusetts p, Title 5 Official Inspection Form - o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` . 43 Erin Ln. Property Address Pat Devine Owner Owner's Name information is H annis required for every y MA 02601 8/2/2019 . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil signs of hydraulic c failure 9 Y , level of ponding, damp soil, condition of vegetation, etc.): 5-3050's with stone in a 10'x40'x2'. No standing effluent in chambers during inspection. No evident stain. No sign of overloading or hydraulic failure. t 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F 4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 Erin Ln. Property Address Pat Devine Owner Owner's Name information is required for every Hyannis MA 02601 8/2/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Erin Ln. Property Address Pat Devine Owner Owner's Name information is required for every Hyannis MA 02601 8/2/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below - ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 116 of 118 Commonwealth of Massachusetts P Title 5 Official Inspection Form _ <Is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 43 Erin Ln. Property Address Pat Devine Owner Owners Name information is Hyannis required for every y MA 02601 8/2/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check'cellar ® Shallow wells Estimated depth to high ground water: +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: 2003 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: Test hole data per plan on file at BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. . t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Erin Ln. Property Address Pat Devine Owner Owner's Name information is required for every Hyannis MA 02601 8/2/2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 L-�JJGJJfil�' t�J-DUllt I.QfUJ_ ra�c 1 ul� , o TOWTI OFBARNSTABLE >~r�ox `1 {`C R`- SEWAGE# VILLAGE 5 ASSESSOR'S MAP&LOT -fir INSTALLER'S NAME&PHONEVO. 5 SEPTIC TANK CAPACITY ^T e ! J LEACHING FACUM:(tyt &bau E..-- (size) NO.OF BEDROOMSl44L_ BUILDER OR OWNER XAC ra- PERMITD'ATE: COMPLIANCE DATE: 31 3 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 teaching facility) Feet Furnished by Id I https://townofbarnstable.us/Departments/Assessing/Property Values/HMdisplay.asp?mapp... 6/11/2019 CARMEN E. SHAY (508)-548-0796 ENVIRONMENTAL SERVICES,INC. P.O.Box 627,East Falmouth,MA 02536 October 30, 2003 RE: Certification of Title V Septic System Installation: Residential Property 43 Erin Lane, Barnstable,MA Dear Sir or Madam: On October 17, 2003, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at 43 Erin Lane, Barnstable, MA, based on a design drawn by Shay Environmental Services on October 16, 2003. I Certify That The Septic System Referenced Was Installed Substantially According to the Plan I Certify That the Referenced Above Septic System Was Installed With Changes but in Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow. The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is Required. If you have any questions, please do not hesitate to call the undersigned at (508)-548-0796. Sincerely, CARMEN E. SHA Y ENVIRONMENTAL SERVICES,INC. CARNAEN \T 1 E. i` HAY o. 1181 Ca fen E. Shay, R.S., C.S. �isT�R President v7 d I C� 1 11" I TOWN OF BARNSTABLE L)CATION SEWAGE # ;;M VILLAGE_ � Vc..d ASSESSOR'S MAP & LOT Z -Ol -4 INSTALLER'S NAME&PHONE NO. C SEPTIC TANK CAPACITY LEACHING FACILITY: (tYP3_ a� (size) � L6 /� NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 03 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by o rz 1% 1 OOH �j .4 L-O-,C-NT ION SEWAGE PERMIT NO. ,Ler- 7 V lilt LAGE e�/y,p ell. INSTA LLER'S NAIVE i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED /p iyf3 DATE COMPLIANCE ISSUED i ice. l 4 y � V TOWN OAF BAARNSTABLE LOCATION SEWAGE# VILLAGE. ASSESSOR'S MAP & LOT Z��17 INSTALLER'S NAME&PHONE NO. SEPTIC.TANK CAPACITY 072 Ci 4k4 LEACHING FACILITY: (h'�.ne1Gc� (size) cSCL� �' ,.. NO.OF BEDROOMS BUILDER OR OWNER. 3P PERMITDATE: COMPLIANCE DATE: 3 Separation Distance Between theme Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility _ Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Within 300 feet of leaching facility) Feet Furnished by. i i I i PGA �i p ` No.20 03_S// FEE ��V �- C®MMONWLAIT14 ®F MASSAC14USETTS Board ofHealth, iU :— MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ❑Complete System ❑Individual Components Location 13 tktn) &?t7 j,— Owner's Name Map/Parcel# Address Lot# 001Telephone# Installer's Name Designer's Nam ��5 Address P.O. , 5 Z(pb I Address P,® IA7* n)6d 0d_-s? Telephone# 4;6 _ Telephone# -6 Type of Building Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min requ' ed) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) �t.�l Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation s DES RIPTION OF PAIRS OR ALTE TIONS e- r IA�," 5, / E ,.r,P.►C' wGINL ;UST r.. The and rsigned a ees to install the above described Individual Sewage Disposal System in"accords cV`k1lrthe provisions of TITLE 5 and further a es to t to place t m in pe til a Certificate of Cogs 'ance has 6eeu'issued4by 1e,'l d of-Health.- ' •;yfa����l.Ft4t1. Signed Date Pnspections /2-603 . ,,oy�{�-„r .ss4J'.-.�.,,�:..- - •�"ir: �y'Wx' �.�"t T'+t.,.»^+,.. --"*r'r:,Fa'-ua's...: � ynrv.yy,�.+�S-f..� .},.rr-:.i" n-.l+'k..-?�J" --?ry...l� 6 f No.Zp o3 sI I .. .. k FEEi- "—Sri.....:: 1 -�� t COMMONW1AETI4 Of MASSAC14USLTTS � �C Board of Health, �n: Ki!Y )1 __. MA. APPLICATION FOP, DISPOSA SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( )-Repair O Upgrade Abandon O - ❑Complete System ❑Individual Components Location h6 ' 14LIC/?/?fe Owner's Name 04011 Map/Parcel# ?q I - Oil Address .,,, / Lot# ���'� Telephone# ` Installer's Name Designer's Name C. � Address , hh g r �j/ !`C't-f f�5 b 2 t� Address �. 7 �lit NimADd 5?10 Telephone# '1 _I , Telephone# 'Y ,_6- Type of Building r� jj ��a Lot Size sq.ft. �^>F- Dwelling-No.of Bedrooms _ Garbage grinder ( ) Other-Type of Building } et No.of persons Showers r( ),Cafeteria ( ) n f Other Fixtures Q 1 JJ'' ' r f t DesigTi Flow (min.required) , L4 `�f 0 gpd Calculated design flow Design flow provided-q gpd Plan: Date f�� 1U �3 Number of sheets Revision Date h"Title p�rryy Description of Soil(s) R,J� 1�'� Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation l DESCRIPTION OF REPAIRS ORALTE TIONS 1 al e- r lr.t i'xTaLl G r• u T4/se V ig _ , ) - - The undersigned agrees to install the above.described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees ton not �to place thAn-,t/ems in overationuntil a Certificate//o�f`Comp/liance has been issued by the Board of Health. Signed . X t%/ Date V r r b�,< S 0�2��a3 sp"tions R , No. ,t�3-5/ C®�'l[�'1ONW[A.�.T14.OF MASSACHUSETTS FEE S� Board of Health, ! .! CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) "E Complete System /� The unde signed hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded (} Abandoned ( ) by: � �ivh T- , l t r at has been installed in accordance with the pr vtsio^np of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to applicatio`n,No. 2-003,-S1(,-)dated (Q�/ -�13 Approved Design Flow (gpd) � Installer Designer: v ' Inspector: i' i( _ Date: 1'Q�3! Q 3 v •:, The issuance of this permit shall not be construed as a guarantee that the system will function as designed. T No.?-Dos SI FEE J V COMMONWEAL:11' OF MASSAC14 SETTS Board of Health, JU( /4,b MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permiss+iof n is hereby granted to; Construct( } Repair((j ) Upgrade(�)� Abandon( ) an individual sewage disposal system at '-Y�� c I( e, as described in the application for t- - ' Disposal System Construction Permit No.ZQ1ifi—S/1 , da-ted / ) 2v c3 . Provided: Construction shall be completed within threeyears of the date of this perm' -1 ocal coed*`ns must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date C D 20/G Board of Health 5eN - 20-01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 N • UL • s�zstot NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM (I..'e-4 SvInS4 hereby certify that the engineered pian signed by me ua;ec 10116 ( , concerning the property located at 425 LC t -t e+,eti(1S meets all of the following �ntetia This failed system is connected to a residential dwelling only. There are no .omm--rcia! or business uses associated with the dwelling, • 'F? e soil is ciasstf:ed as CLASS l and the percolation rate is less than or equai to -n:nutts per inch. The applicant may use historical data to conclude this fsc: or may :onduct tests at the site without a health agent present. • There :s no increl;e to flow and/or change in use proposed "Chen are ,to variances requested or needed. The bottorn of the proposed leaching facility will not be located less than fourteen 1;) iee: aoove the maximum adjusted groundwater table elevation. (Adiust the ;-nundwatcr table using the Frimptor method when applicable) Please complete the following; �. Top of Ground Surface Elevation (using GIS information) 6 G.Vv' E icvat:on, � Q 0_ • a d;ustncnt for .nigh G.W. Ft FRE�t�F BETWEEN and B S:UVED DATE: 10 O ' :;asec jron t;-,e above ir.formsuon, a reoair permit wil! be issued for _ bedroorr-s -ra..imum `o ,,ddtu:onal bedrooms are authorized to the future without engtncerec i:ept.c sy:'attm plans. s �t:nh!r:aci puccxm Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Locations 4 ?�a �Q —,��� A— Lot Lot No. Owner: t�e�.�Q_ l�C'�r,�nc Address:_ �p Contractor: S F".%. Addres^s?6,1 G��- � '�C �rnn� M 1� ci zslto Notes:_ ��Mt � 1)2,,-K0 (1 STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .Date morit /day ear STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... Mt OBWater-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... 101 os -( mont /year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment ............................................... O� 1 STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water r� level at site (STEP 1) ...................................... . ..................................... oca• Ir ' Figure 13.--Reproducible computation form, 15 � SECTION A A ALL OUTLET PIPES FROM THE 10' min. from-- *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. DtsrRleunoN Box SHALL.13E Existing Foundation house to septic tank ---�--' - - v- 12" CONCRETE COVER J PROFILE VIEW OF LEACHING SYSTEM SET LEVEL FOR AT LEAST 2 FT. Septic tank covers must he r-:: - 3 TOP OF FOUNDATION = ELEV. 100.00 (Assumed) Not to Scale - -T within 6 In, of finished grade �Grode over SAS - ELEV 98.50 I 3 - 5"OUTLET �.'":""�''- -z- Y Grade over Septic Tank - 98.50 (:rode over D-Box - 98.50 f// _ KNOCKOUTS _ - 3" of 1/d' - I/2" lrashsd Psacto - i I >-• 9/4' W 1 1/R !lashed C'swhsd Stone 5.5" _OUILET i(� 72" INLET may' S 0.02 3 HOLE H-10 3' Maximum Cover Top Load - Elev. =95,B3DIST HOL BOX <.:.i NEW S=O.oi o Greater To of SAS-Etev.=95.50 -t5.5'- Fnn Ln v 27' -- P 4" - SCH. 40 Te -'7.75" Fxlr PIP u� 1,500 GAL. sm o.ot" per foot +. FROM FOUNDATION rn SEPTIC TANK LO 20 t - (6 H-10 20 f - � " PLAN SECTION CROSS SECTION ` O O -2' Effective Depth o II os,asMs rn N o u, 24' Effective 11 o _ CONCRETE FULL FOUNCATI i � SWerall 11 o & 5 units R 7' = 35' 3 HOLE H-10 DISTRIBUTION BOX m B rn SYSTEM PROFILE 6 in.of 3/4"-1 1/2" " i 3' " 3' a_ - a compacted stone i II -•--4= S --35'- _�5r NOT TO SCALE E Ju i u u i rn Not to Scale c v � 6 c EFfective Width --4�-- --r. 6 in.of 3/4'-1 1/2" Effective Length GENERAL NOTES compacted stone ° SOIL ABS❑RPTI❑N SYSTEM (SAS) 1. Contractor is responsible for Digsafe notification NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE ; �° INFILTRATOR MODEL 3050 (H-10 LOADING)/ SUMNER & DUNBAR and protection of all underground utilities and pipes. Bottom of Test Hole t Elev.=86.50 OR EQUIVALENT) 2. The septic tank and distribution box shall be set ( level on 6" of 3/4'-1 1/2" stone. - NOTE: OVERALL HEIGHT OF INFILTRATOR IS 30" /EFFECTIVE HEIGHT IS 24' 3. Backfill should be clean sand or gravel with no _ _ __ - ---- ---_--- ------------. -. --- ------- stones over 3" in size. 4. This system is subject to inspection during installation by Carmen E. Shay - Environmental Services, Inc. TEST 5. The contractor shall install this system in accordance PEROO�AIION I � with Title V of the Massachusetts state code, the approved plan EST - and Local Regulations. � 7� T 6. If, during installation the contractor encounters any Date of Percolation Test: September 30, 2003 s ' �1 v LA 1 !� ��1 soil conditions or site conditions .that are different Test Performed By: CARMEN E. SHAY, R.S., C.S.E. from those shown on the soil log or in our design Results Witnessed By: WAIVER ( per Barnstable B.O.H.) 77 installation must halt & immediate notification be SHAY ENVIRONMENTAL SERVICES, INC. (40 FOOT RIGHT OF WAY) Percolation Rate: less Than 2 MPI © 40" 7 � made to Carmen E. Shay - Environmental Services, Inc. 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. I Test Hole \ -_ - 1 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. \. No. 1 \\R = 52.50' 10. All solid piping, tees & fittings shall be 4" diameter DEPTH SaLs ELEV. I / ` Schedule 40 NSF PVC pipes with water tight joints. 0- 98.50 ---` 1 1. Municipal Water is Connected to ALL OF The Residence and Abutting L : Properties Within 150 Feet. 51.55' Loamy -f- \ / ---- --- -----and --.- 10 YR 3/2 0 8" AP 97 75 I �` � THE PROPERTY LINES ARE APPROXIMATE AND COMPILED FROM THE SURVEY PLAN GENERATED BY Sandt <�' WILLIAM LIEBERMAN, JOHN DOYLE, RLS. OF FALMOUTH, MA Loamy 9� II ,� 10) ENTITLED " CERTIFIED PLOT PLAN OF LAND OF #43 ERIN LANE, 10 YR 5/6 - f � t v BARNSTABLE, MA" DATED SEPTEMBER 30, 1983, e"- 40" e. 95.25 a. AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN Medium \ I IT SHOULD BE USED FOR NO PURPOSE OTHER THAN Sand �, I ---THE SEPTIC SYSTEM INSTALLATION. - 2.5 Y 7/6 40"- 144' _C 86.50 1 -- PROJECT BENCH MARK 1 0 EXISTING SEPTIC TANK & LEACH PIT TO BE PUMPED OUT AND TOP OF FOUNDATION FILLED IN PLACE, AND OR REMOVED. ELEV. = 100.00 (Assumed) NOTE:I g8 ANY STRIPPED OUT SOIL CONTAINING LEACHATE Failed Leach Plt FROM THE. EXISTING LEACH PIT TO BE DISPOSED LOT #6 OF AS PER BOARD OF HEATH SPECIFICATIONS. I NO rvtTLHNw 1R rnESE.yt -,v iTr_t.1N 200 OF I r-,r S ROPER;Y' L07 #8 - 1 EXIST. 1000 gpl. -ASSESSORS MAP 291, PARCEL. 017 LO Perc #1 T #007 - - Perc:40" to 58" HOUSE #43 Septic Tank (TO BE REMOVED) Depth I Perc Rate= Less Than 2 MPI 1 `- I 11 NEW LEG G E N D No Observed ESHWT EXISTING I 1500 gal. No Groundwater Observed 0132" ="-- -�.�! �y 4 BEDROOM -- L_ ` Q Q Septic Tank �04X1 DENOTES PROPOSED O� HOUSE DECK Q TEST HOLE #1 SPOT GRADE EL_EV.= 98,50 c°' 27.5', _ - 12 x 104.46 pPOTTES GRADEISTING �``� _ `' •: t l PL PROPERTY LINE LOT #7 - -- `98._ 13,315 square Feet +/- ; 96P PROPOSED CONTOUR j D-BOX -- - - -- ------ EXISTING CONTOUR 16.5 111.3C DEEP TEST HOLE & _ 3-24" DIAM. ACCESS MANHOLES , v N 88d 36 49 W -�� PERCOLATION TEST LOCATION -'----"' --- -.- to' -6" - 6 FOOT STOCKADE FENCE INLET NL L�ET W ETTHE ACCESS COVERS FLOT THE SEPTIC TANK, DISTRIBUTION BOX ANDOLEACHING COMPONENT P AN SHALL BE RAISED TO WITHIN 6" OF -. -•.- _. �: - FINISHED GRADE. t OF PROPOSED SEPTIC SYSTEM UPGRADE STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITS GAS BAFFLES OR EQUALS � �� � PREPARED FOR ON ALL OUTLET TEE ENDS r a a PLAN VIEWf: l1g � • 3-24" REMOVABLE COVERS � � F �� YY' S A M U E L M . H U T C H I N G S fir. 9 F•: - A.T. - s:,,•" 3' min. clearance •,3 j�_"NLEY"r' #43 E R I N LAN E INLET 8" mi --- min Inlet to outlet 6 min. _ -Li �1--L�� OUTLET ILIi H YA N N I S M A I �� 5• -7- -- i-- I 5• -7" �..�.. Liquid depth Design Calculations -- E" �a ` < s PREPARED BY: :....,•: Garbage Grinder: No ':);`,f Number of Bedrooms: 4 Existing, Equivalent to 440 Gal./Day (440 Gul./Day Min. per Title V) ' g ; + CYARHEY E# SffA Y S -a Leaching Capacity Proposed: 440 Gal./Day Minimum (Min. Per Title V) - CROSS SECTION END-SECTION Septic Tank : - 2 x 440 Gal./Day = 880 USE 1,500 GAL. Septic lank. 1�"` ram ' I ENVIRONMENTAL SERVICES, INC. ROSS - SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch O 20 40 50 �33t\`• 1"'O 1' �T 1 Bottom Area: 0.74 gal/sq. ft. x 400sq. ft. = 296 gallons - ` r'/ � 1 P.0• BOX 627 TYPICAL 1500 GALLON SEPTIC TANK Sidewall Area: 0.74 gal./sq. ft. x zoo sq. ft. = 148.00 gallons _ _-- Providing: _ 444.00 gallons EAST FALMOUTH, MA 02536 TEL/FAX : 508-548-0796 NOT To SCALE SCALE: 1 "=2.0' ---- ------ _._---- -_-_---- -- (�{- LOADING) Use: (5) HIGH CAPACITY INFILTRATOR CHAMBERS, HAVING A 2' EFFECIIVE DEPTH, SCALE: 1 "=20' DRAWN BY: CES DATE: OCTOBER 16, 2003 (4' W x 7' L) TO BE USED WITH 3' OF WASHED STONE ON THE SIDES AND 2.5' of WASHED STONE ON THE ENDS. PROJECT#SD488 FILENAME: SD488PP.DWG SHEET 1 OF 1