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Home My WebLink About0037 FRANKLIN AVENUE - Health 37''Franklin Avenue Hyannis A= 292 - 038 ° i. D O ° , p n a a O I a 2 o D k a yy u n 1 I K k a 7 n u e p u � TOWN OF BARNSTABLE LOCATIONV7�-'944<1;6� Ate- SEWAGE #0V007-3j f VILLAGE lljrd,7/1i.S ASSESSOR'S MAP & LOTA9-2, 35 INSTALLER'S NAME&PHONE NO.e!?O AJl dazg!k—,a i%V-w(/,V—MEL SEPTIC TANK CAPACITY /5�V 46/I(AS' LEACHING FACILTTY: (tyWR) T,��neAxe (size),5 'X5 X NO.OF BEDROOMS BUILDER OR�O - e A(L+- , PERMTTDATE: ?"(A % COMPLIANCE DATE: A9 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 r �� i I - 038 Commonwealth of Massachusetts Title 5 Official In Form Subsurface Sewage,Disposal System Form -Not for Voluntary Assessments'/� of�y'�►'V j y 1 I Property Address I Owner Owner's Name information is g�yj t St4 0j &0, required for every -- — page. City/Town I State Zip Code Date of TnslifectioA 1 Inspection result's 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. Inspecto I o ation filling out forms / l on the computer, use only the tab Yr - key to move your Name of Inspector �— cursor-do not I 1E&V10 use the return Company Name key. Y10 0 U VI1m I I Company Address v alb Vol CitylTo l V 0 / 90 State l 4�� Zip Code .; Iz Teleph a Number, License Number 1 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 maiEPa a of on-site sewage disposal systems.After conducting this inspection I have determined that the m. 1. sesl 2. ❑ Conditionally Passes I � 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fail I Inspect 's Sig'nature Date The systems inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or,DIEP)within 30 days of completing this inspection. If the system has a design flow of 10.000 gpdJor,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. I l Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7f262018 j Title s official Inspection Form:Subsurface Sewage Disposal system•Page 1 of 18 l 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A Property Address Owner owner's Name �7 I / ✓ o� information is ]� required for every 1W) h M _-- 0v 40 page. City/Town U, 1 State Zip Code Date of I spe &ion C. Inspectio; Summary Inspection Su mary: Complete 1, 2, 3, or 5 and all of 4 and 6. i I 1) Syste aisle I have not found any information which indicates that any of the failure criteria described in 310 CMRI15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. I Comments: I I i i 2) System Contlitionally Passes: i ❑ One or more system components as described in the"Conditional Pass" section need to be replaced orlrepaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the bolx 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. i ❑ Y I❑ N ❑ ND (Explain below): i I i i l t5insp.tloc-rev.72620i8 Title 5 OKicial Inspection Form:Subsurface Sewage Disposal System•Page 2 of 78 i i i I I Commonwealth of Massachusetts P Title 5 official Inspection Form Subsurface Sewage Disposal System Form -fNot for Voluntary Assessments ...�5 � i / l I G n Yf!r✓1 Property Address S Owner Owner's Name information is required for every Ci✓1 1 O j�o/ r 3 oZJ page. C4frown State Zip Code Date of inipecan C. Inspectio! Summary (cont.) 2) System Conditii nally 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 for obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass insp i ction if(with approval of Board of Health): ❑ b o len pipe(s)are replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below): it i I i— I ❑ 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): i ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): I _ — i l 3) Further Evaludtion 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 lis 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 a i d the environment: I t5insp.doc•rev.7262018 i Title 5 Official Inspection=onn:Subsurface Sewage Disposal System•Page 3 of 18 I I i i it Commonwealth of Massachusetts Title 5 Official Inspection Form -Not for Voluntary Assessments Subsurface Sewage Disposal System Form 13 ? a r► 411)VA ,r Property Address l _ / I I S T'�l✓G-/ Owner Owners Name ` l information is / i q A✓1 I S � b d'�0 required for every page. Cityrrown i State Zip Code Date of Ins olio C. Inspect'n Summary (cost.) I ❑ Qeisp ul 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 a i d 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 w�ellI ❑ 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: I i **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: j I I 1 I I I I � 4) System Fail Ire Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes i IN o ackup of sewage into facility or system component due-to overloaded or clogged SAS or cesspool ❑ i Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool rev. i Title 5 Ofridal Inspection Form Subsurface m Sev2ge Disposal System- 4 o t l5insp.doc• 72MM i I • i Commonwealth of Massachusetts if Title 5 Official Inspection FormSubsurface Sewi ge Disposal System Form -Not for Voluntary Assessments rn 44 14 Property Address Owner Owners Name information is ,AnV1 fs �)60 / required for every / ✓ 1 page. City/Town ; State Zip Code Date of 14ectibn C. Inspectl61n Summary (cost.) i 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 i or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less ❑ I than '/2 day flow ❑ Required pumping more than 4 times in the last year NOT due to dogged 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. ❑ I ( Any portion of a cesspool or privy is within a Zone 1 of a public water supply Eel 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 i from a private water supply well with no acceptable water quality analysis. [This j 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. i ❑ The system fails. I have determined that one or more of the above failure j 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 inecessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow Iof 10,000 gpd to 15,000 gpd. For large syste I s, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section C.4. Yes No I ❑ ❑ 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 i ❑ Q 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 i tSinsP•doc•rev.T126=18 I Tide 5 Oiricial Inspection Form:Subsurface sea se Disposal system-Page 5 or 18 i I i . j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sew i ge Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every I U✓I��S 1 '' page. City/Town State Zip Code Date of In pec on C. Inspectiolin Summary (cost.) i If you have an "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 Ci4 shall upgrade the system in accordance with 310 CMR 15.304.The system owner e appropriate regional office of the Department. should contact th 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes ,o I ❑i Pumping information was provided by the owner,occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? P P ❑ s 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? j Were all system components, excluding the SAS, located on site? ❑I 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? ❑I Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? j/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. ❑i 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)] I i j I I j tSinsp.doc•rev.7/262018 I 71de 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 18 i I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 •3' T /Ghl�+� rrr= Property Address I c.J Owner Owner's Name information is /� l required for every M Af S �/7 0d 60 3 page. City/Town ; I State Zip Code Date of I spection D. System Information - 1. Residential Flow Conditions: 7)�� oA Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms}- Description: i �So'D ��, l(o,� tG v►�/ f /J r.r'�!00 � • ev1 Q i I 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 Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: I i ---- - Sump pump?; I ` Y No i Last date of occupancy_ Dat L5insp.doc•rev.72&M18 Title 5 Official Inspection Forth:Suosurface Serfage Disposal system•Page 7 or 18 I i i i . I Commonwealth)of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t F114;ev�_/V17 Property Address 1L (I 1 e WC.0— Owner Owner's Name information is O 3 required for every � G A�1 l _ (/ page. City/Town I State Zip Code Date of In pecti n D. System reformation (cont.) 2. Commercial/industrial'Flow Conditions: I Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design low(seats/persons/scl.ft., etc.): Grease trap present? ❑ Yes ❑ No I Water treatment unit present? ❑ Yes ❑ No i If;yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No I Non-sanitary wai to discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: i Last date of occupancy/use: Date Other(describe below): I I 3. Pumping Rego Ids: O Source of information: - 2-� �v Was system pu 1 ped as part of the inspection? ❑ Yes No If yes, volumeipumped: gallons How was qua nit it�y pumped determined? Reason for pumping: i t5insp.doc•rev.7126=18 Tide 5 Official Inspection Form:Suosurface Sewage oisposai System•Page 8 or 18 I . I Commonwealtih of Massachusetts kloTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments iw I 3 / �av►l�(��h Ave-- Property Address J �r Owner Owner's Name information is AA ojwrequired for every G1✓1 � 10 J page. City/Town State Zip Code Date of spe tion D. System nfo mation (cont.) i 4. Type of S to I: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ bverfiow cesspool I ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) t ❑ ' Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all com onents, date installed (if known) source of information: i to Were sewage odors detected when arriving at the site? El Yes ❑ No 5. Building Sewer(locate on site plan): t/ ao Depth below grl de: feet Material of constructi;/40 , I ❑cast iron PVC ❑ other(explain): l /f7 Distance from i private water supply well or suction line: fit Comments (on condition of joints, venting,evidence of leakage, etc.): l t5insp.doc•rev.7262018 Tide 5 official Inspection Forth:Subsurface Sewage Oisposal system•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address I Owner Owner's Name I ' /J information is A 53 a- required for every ��f page. Cityfrown I State Zip Code Date of tnspection D. Syste Information (cont.) 11 6. Septic Tank (lo i to on site plan): Depth below ral e: 9 feet Material construction: I concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) � I If tank is metal, Mist age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate Yes ❑ No Dimensions: Sludge depth:: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from tip of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle i How were dime sions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels a'rielated to outlet invert, evidence of leakage,etc.): o v. IV Go f tef I _ t5insp.doc•rev.7126=18 Tide 5 Official Inspection Form:Subsurface SewaSe Disposal System•?age 10 of 18 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage?Disposal System Form -Not for Voluntary Assessments v� Property Address I Owner Owner's Name r information is required for every l A vl/1!S _ Al d� 4 page. City/Town ' State Zip Code Date of I spection D. System In',formation (cont.) 7. Grease Trap (locate on site plan): I Depth below grail e: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness --_ I Distance from1 to,p of scum to top of outlet tee or baffle Distance from but tom of scum to bottom of outlet tee or baffle Date of last pumfping: 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.): I 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below gr lde: — i Material of construction: i ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: -- Capacity: gallons Design Flow:i gallons per day l5insp.doc•rev.7/26/2018 Tide 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewige Disposal System Form -Not for Voluntary Assessments Property Address I S�bt�Gr Owner Owners Name information is 141") /�required for everyG►0 V, �_1 0.) �O f) � s 3 a� page. City/Town ; State Zip Code Date of Ins Clio D. System Information (cost.) 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 Hof 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 V Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leafage into or out of box, etc.): i I.Sinsp.doc•rev.72&M18 Tide 5 Ofriciai Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth lof Massachusetts Title 5 O!' Disposalicial Inspection Form b Subsurface Sewag System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every �A�✓1(s l0 page. Cityrrown C ; 1 State Zip Code Date of Inspe ion 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 locat Id, explain why: I Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ aching galleries number: / 25 )37� leaching trenches (.�L / number, length: ❑ li aching fields \ number, dimensions: ❑ overflow cesspool number: ❑ Innovative/alternative system Type/name of technology: -- ------ LSinsp.doc•rev.7/26=18 I Tittle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 18 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 AXL required for every page. City/Town I State Zip Code Date of Ins rpectitin D. System Information (Cont.) 11. Soil Absorptib n System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): -- I O vle— Cti �O/ / Cl 4n Ga C r . I - 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): it Number and configuration Depth—top ofli quid to inlet invert it Depth of solids layer Depth of scum layer Dimensions ofic sspool — 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.726=18 Title 5 Official Inspection=om Subsurface Sewage Disposal System•Page 14 of 18 commonwealth of Massachusetts Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information isVp�lp�/ required for every Lie page. City/Town i j State Zip Code Date of Inspebtiorr D. System Information (cost.) 13. Privy(locate on site plan): Materials of co'nstruction: - Dimensions Depth of solids — Comments (note condition of soil, signs of hydraulic Failure, level of ponding, condition of vegetation, etc.): � I : I I tsinsp.dod•rev.726=18 Tide 5 Official Inspection Form:Subsurface sea se oisposal System•Page is or is i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewag I Disposal System Form •Not for Voluntary Assessments Property Address Owner Owners Name /� information is H y Von 6 / .2 required for every page, City/Town State Zip Code Date of Ins ectio D. System Information (cont.) 14. Sketch Of Sewage sp al System: Provide a view he sewage disposal system, including ties to at least two permanent reference landmarks ,e i chmarks. Locate all wells within 100 feet. Locate where public water supply enters the buil ' g. Check one of the boxes below: j hand-sketch)in the area below drawing attach ed separately J i t 16 of 18 t5insp.doc•rev.7/26/2078 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page I ' r , � t j TOWN OF BARNSTABLE LOCATIONV Ate, SEWAGE N-1007-IV7 VILLAGE "Aran i.S ASSESSOR'S MAP&LOTEIE � INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY d&kwf LEACHING FACILITY:(typq(2 ��ef (3ize)3fX31t2 'NO.OFBEDROOMS 3 i Buff bER OR n A PERMITDATE: —a3,o% COMPLIANCE DATE: f7 a4 I iSeparation Distance Between the: Maxiniuml 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) Fat Edge of Wetland and Leaching Facility(If any wcdands exist withi01300 feet of leaching facility) Feet Furnished by %_0 - i I I j i • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syst em Form -Not for Voluntary Assessments Sig T /ar�l��t lei Property Address St L./b Owner Owner's Name I / �ainformation is required for every G Nis __ A1,4 o. &&O _ s page, City/Town I State Zip Code Date of Inspection j D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow well /d- Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: I ❑ Obtained from system design plans on record If checked, date of design plan reviewed: — Date ❑ Obs Irved site (abutting property/observation hole within 150 feet of SAS) ❑ Che ked with local Board of Health- explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must desc ' how you established the high ground water elevagt o�n: u o u o''�,ff le /0 C— C/ I L& Before filing ithis inspection Report, please see Report Completeness Checklist on next page. 1.5insp.00c•rev.7126t2018 Title 5 Ofrivat Inspection Form:subsurface sewaGe Disposal system.Page 17 of 18 . i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name /f/f � information is i �N�� / 11SL y (0 required for every -- page. CitylTown I State Zip Code Date of In pect on E. Report tompleteness Checklist Complete all applicable sections of this form inclusive of: ` I A. houpecter Information: Complete all fields in this section. �Crtification: Signed& Dated and 1, 2, 3, or 4 checked lnspection Summary: 1, 2, 3, or 5 completed as appropriate 4 ailure;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 Title s official irspection Form:Subsurface Sewage DiSposal System•Page 18 of 18 t.5insp.doc•rev.72612018 No. OU� �17 Fee V 9 THE COMMO At! HUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTAB.LE, MASSACHUSETTS Yes pplication for ]Digpogal 6p5tem Con0tructfon Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No:3� re- nxl; AVV- Owner's Name,Addressd Tel.No �.Ja ewe4r Assessor's Map '� �? ��/�n 4W— Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.-P4V, O 1374 r-0'J) Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder (0 Other Type of Building No.of Persons 2-L Showers( ) Cafeteria( ) Other Fixtures l/ Design Flow(min.require ) !f y gpd Design flow provided gpd Plan Date Number of sheets 2 Revision Date Title Size of Septic Tank �VU Type of S.A. rx 3 7 6.4) (i3) Description of Soil �n j IUon'1 3,4 dl 0 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of t e Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B and Health. Signed Date !'" 7 Application Approved by Date 7 —.1.3"0`7 Application Disapproved by: Date for the following reasons Permit No. a0 0 7 Date Issued 7— of 3—o-7 ~sl ifi o ' No. .l�O C� /I / �• O `I Fee �' •' THE COMMONWEAL-TH-OF-M-ASSACHUSETTS Entered in computer: �x . PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for ;Dt9;Poga1 *raem Con0truction ijermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No.3 7 Owner's Name,Address,'and Tel.No. Assessor's Map arc F 3, FZf4K1ir1 40Z_ 7 Installer's Name,Addressluld Tel.No. Designer's Name,Address and Tel.No.//AI/i 7 /yi9�v.✓ L �'':��`T�.,n Ro ,�h�:�v.;,•.� b,f'9/ 'PeS, n S ArT S�•,�w�. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder (X)9 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ar Design Flow(min.required) Po gpd Design flow provided -3 3 G7 gpd _ Plan Date Number of sheets �— Revision Date Title L.. Size of Septic Tank UV Type of S.A. ..,,P -5 S-k 3 acwoic S Description of Soil n Q I 4 Nature of Repairs or Alterations(Answer when applicable) x - w Date last inspected: r 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 oft q Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B rd o Health. Signed Date 1-21_p Application Approved by Date 7 —.2 3- Application Disapproved by:' Date for the following reasons Permit No. P00 7 — Date Issued 7— A 3'O THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certiftcate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (�. Upgraded ( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Constructiln Permit No. D O 0 7 - _3 (? dated 7 Installer CA1,� Designer floaCO`^ #bedrooms Approved design flow Z536 gpd The issuance of thisnpe iit shall of be construed as a guarantee that the syst will fu do de 'gned. Date / d-�� Inspect -------- 7007I----------------------------- No. 20c) — I7 Fee /61c) . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1=t2;Po5aY 6pgtem Con5tructton Permit ),e Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ,. ). Abandonr- ~` System located at 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. f% Provided: Construction must be completed within three years of the date of this peWiT7-- Date -71 �� o Approved by Town of Barnstable" &AME,r Regulatory Services *. Thomas F.Geiler,Director + NSFA-B X a Public Health Division ATFD �, Thomas McKean,Director 200 Main Street,Hyannis,IOTA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: Designer: /'�y 1 �j . 1�� Installer: �L &wl DPI I Address: . Address: `' On —d 3-r 6 ®•cJ�Gt�4MP6 !/ was issued a permit to install a (date) L (installer) ''� 11 t, septic system at 47 t�'�W �� tT W)/based on a design drawn by (address) dated4"), (designer) . Icertify that the septic system referenced above was installed substantially according 'to dll T'" 1e design, which may include min e or approved changes such as lat . location of the ttibution box and/or septic tank. I cer ilhat the septic system referenced above was installed'``wit$'°na€a': jr.chars es'('' greater&4A.`10' lateral relocation of the SAS or any vexti'cai'.ireloga itsn o£any component, of the.septsksy'stem)but in accordance with State&Local'RegEilations. flan revision ok certified as-bu4t`by designer to follow. ; _ AVID- cy taller s ignature) :' B e ' 119ASOR A A(Degner's Signature} (Aff x '.e. i.Q�e ''s.Stathp Here) PLEASE RETURN TO BARI,& t'A_Rf.F'"PUBLIG.'HEALTH.DIVISION: CFR�C T OF COhd WNCE WIIE=1V0 F11SSUEDa= BOT ti.'=TMSI iFGR.m, BUILT'CARD ARE RECEI ABLE PUBLIC 11 SI4W TRUNK YOU , Q:Health/Septic/Designer Certification Farm � ? t Town of.Barnstable P IN A # Department of Regulatory Services 's � : Public Health Division�. Date t6�q �s ,200 Main Street,Hyannis MA 02601 Date Scheduled\J Time' Fee Pd. So uitabili Assessment for Sewage Dis osal o p Performed By: D Witnessed By: o ) LOCATION¢z GENERAL INFORMATION / Location Address'~4 Owner's Name !� �f y� #15 Address Assessor's Map/Parcel: s O1_0 Engineer's Name NEW CONSTRUCTION /REPAIR �� r Telephone# Land Use Slopes(%)~~ / Surface Stones Distances from: Open Water Body ft Possible Wet Area' y"fir ft Drinking Water Well ft Drainage Way # ft Property Line T (y ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate yetlands in proximity to holes) St Parent material(geologic) 00TW V\6 H Depth to Bedrock } 00 Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater N'A ' DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: _in. Depth t0 Sall MOR1e3: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor s- Adj.aroundwater Level,..� PERCOLATION TEST gate ,- '1'Itne Observation Hole# Time at 9" Depth of Perc A Time at 6" Start Pre-soak Time @ —f '°'�'- I lime(9"4") End Pre-soak / Rate Min.)Inch ^ Z M'q� rt' , Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- . ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:%EPTICIPERCFORM.DOC My{ 1 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil then Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsis enc o Gravel) U DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil , Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP'OBSERVATION HOLE LOG Hole# Depth from Soil Horizon ` Soil Texture Soil Color Soil Other Surface(in.) ;'~ (USDA) (Munsclq Mottling (Structure,Stones,Boulders. Consistenc Gravel r A DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil " ' Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Con istency. Oraygll Flood Insurance Rate May: Above 500 year flood boundary No_ Yes Within 500 year boundary No Y Yes Within 100 year flood boundary No z Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi u erial exist.in all areas observed throughout the area proposed for the soil absorption system? .. If not,.what is the depth of naturally occurring pervious material? . Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Envir nmental Protection and that the above analysis was performed b me consistent with the required training,expertise and experience described in 3.10 CMR 15.017. Signatur Date 7 / Q:\SEPTICIPERCFORM.DOC r V' ASSESSORS MAP TEST HOLE LOGS ` PARCEL : FLOOD ZONE : X20 F Gtq 8�_,E SOIL EVALUA701? : it l �'� NOTE,.5: _ WITNESS : REFERENCE: L� �r� /�Pc ��, DATE : t,- 7� ., , 1 The installation shall comply with Title V and Town of Barnstable Board of PERCOLA71 ON R,07E : G I � ) ; Health Regulations. 2) The installer shall verify the location of utilities, sewer inverts and septic 7H- I TH-2 components prior to installation and setting base elevations. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first two feet out ofthe d-box to the leaching shall be level.. 4) 'Phis plan is not to be utilized for property line determination nor any other purpose other than the proposed system installation. LOCATION MAP , , - , 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over II10 septic components. r-9, ` 7} The property is bounded by property corners and property lines. 0° L. V\u�L S The property owner shall review design considerations to approve of total f � � ) i � Y � __ design flow and number of bedrooms to be considered for design. Receipt of ` h 74 payment for the plan and installation based on the plan shall be deemed Y +' approval of the design flow by the owner. � t ; 1?.DD n, , 9) The existing leaching or cesspools shall be pumped and filled with material w t✓ ' Kc `-`�"` per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated. soil and replaced with clean washed sand w per Title V specs. n SEPTIC SYSTEM DESIGN 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCII 40 PVC with ends grouted if FLOW LEST I MATE applicable. 11) If a garbage grinder exists it is to be removed and is the responsibility of the I 1/ El:DROOMS AT 11D GAL/DAY/BEDROOM -?W GAL/DAY owner to ensure such. i 12)The installer is to take caution in excavation around the gas line if applicable. �, 13}The installer shall verify the location, quantity and elevation of the sewer lines 1 — SEP7�1':, TANK g w prior to the installation. " exiting the dwcllinC, I r ��i-'!SAL/DAY x 2 DAYS - 0 GAL USE I_00 GALLON SEPTIC TANK So L Af�SdRPT I ON SYSTEM i »r {` t }_V' ` tv'� �`�., ! T)�,.rC.f _ J'a.'.cJ +tr'`,J 4�✓+"",,,..._ _., _ __ _ _ _,__ ; � br ..r old 1 c SIDE AREA: 2SC 5 �- �. �_ X 112,7 ,, _ SON E0770M AREA:Ilk h \ 1 1 SEPTIC SYSTEM SECTION ID 1 C'� l ' Lf + _ F. 40 � ! � i4o .. OX e t n I � GAL }, 11 i! � Ly ]/7 SEPT 1C TANK __ - __ G!i �I+L�✓ ti� d" e a - I SITE AND SEWAGE PLAN LOCAT ION : "'� �I ° AVE PREPARED F 0 R . ��j ` SCALE DAV I D B . MASON R DATE: 71 q 0 z \ DBC ENV I RONMEN�AL .DESIGNS ' EAST SANDWICH . MA ° DATE HEALTH AGENT d`� ( 508 ) 833-- 21 i"7