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HomeMy WebLinkAbout54, 56 FRESH HOLES ROAD - Health J4/56 Fresh.Holes Road. , Hyannis A- 090-174 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54-56 Fresh Holes Rd Property Address Dennis Conners ' Owner Owner's Name information is Hyannis ✓ MA 02601 11-29-17 ' required for every y h..a page. City/Town State Zip Code Date of Inspection 0i rm f• Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information F 1. Inspector: , Shawn Mcelroy ' Name of Inspector Upper Cape Septic Service Company Name P.O. Box 73 + Company Address E..Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. l am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes. - Conditionally Passes, ❑ Fails,, ❑, Needs Further 'o F y the Local Approving Authority., 11-29-17 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 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �PJ�4d VS Commonwealth of Massachusetts z ' Title 5 Official • Inspection- Form 1II Subsurface Sewage Disposal System Form=Not for Voluntary.Assessments a� 54-56 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for every Hyannis '" MA 02601 11-29-17 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: ® 1 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. t Comments: System is in good wroking order with no sign of failure. , B) System Conditionally Passes: El One or more system components as described in the "Conditional Pass"section need to be = I 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)fort I he 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. „ ,4.,• ❑ ;Y ❑ N ❑ ND,(Explain below): t5ins.doc•rev6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 • L Av Commonwealth of Massachusetts Title 5 Official Inspection Form � I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54-56 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for every Hyannis MA 02601 11-29-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will,pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ' ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): F❑ 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 fuinctioning 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts +4 , Title 5 Official Inspection Form i l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54-56 Fresh Holes Rd z. Property Address Dennis Conners Owner Owner's Name information is required for every .Hyannis MA 02601 11-29-17 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 x r y ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool '❑ ' ` ` ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ; ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less t. than Y2 day flow ' t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts i Title 5 Official_ Inspection fo- rmi l 'el Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54-56 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is H annis MA 02601 11-29-17 required for every y page. City/Town _ State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion.of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ' ❑ ® Any portion,of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well'with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence { !of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.]' ;❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd.' The system fails. I have determined that one or more of the above failure ❑ ® criteria exist as described'in'310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000.gpd to 15,000 gpd. -For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑i i _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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts ` f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54-56 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for every Hyannis '{ MA 02601 11-29-17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of t, r this inspection? Were as built plans of the system obtained and examined? (If they were not ® El ' available note as'N/A) ®. ❑ Was the facility or dwelling inspected for signs of sewage back up? -E r❑ - 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: r ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information n Residential Flow Conditions: Number of bedrooms (design): F ` 6 Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 t r t5ins.doc•rev.6116 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts R, Title 5 Official Inspection Form �4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54-56 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for every Hyannis MA 02601 11-29-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? El Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? r• ❑ Yes ® No Last date of occupancy: 11-2017Date Commercial/Industrial Flow Conditions: _ Type of Establishment: _ .-Design flow(based on 310 CMR 15.203): canons per day(gpa) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? k ❑ Yes ❑ No Industrial waste holding tank present?.. k ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I Commonwealth of Massachusetts ^+ f� Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form -Not for,Voluntary Assessments f} a, 54-56 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for every Hyannis MA 02601 11-29-17 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: N/A ' Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous,inspection records, if any) ❑ Innovative/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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts 1a=1 Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary,Assessments 8 p Y rY� a� 54-56 Fresh Holes Rd ' Property Address Dennis Conners F Owner Owner's Name information is required for every Hyannis, MA 02601 11-29-17 + page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) t Approximate age of all components, date installed (if known) and source of information: 2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): , � Depth below grade: 24"feet Material of construction: ' ® cast iron 0.40 PVC ❑ other(explain): ` ' Distance from private 'water supply well or suction line:' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): 18 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: 1500 gal with extra 1000 gal tank Sludge depth: 12" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts . . +; f� Title 5 Official Inspection Form ,Al Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54-56 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for every Hyannis MA 02601 11-29-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" 211 - Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 1411 How were dimensions determined? Tape Comments (on pumping,recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related'to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign,of leakage.Secondary settling tank in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: F ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle ` Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form .WA Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54-56 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for every Hyannis MA 02601 11-29-17 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.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts .. lay ; Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54-56 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for every y H annis MA 02601 11-29-17 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. f • Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts - :a=1 Title 5 Official Inspection Form ;, Subsurface Sewage Disposal System Form -Not forVoluntary Assessments 54-56 Fresh Holes Rd i Property Address Dennis Conners Owner Owner's Name information is required for every Hyannis MA 02601 11-29-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: , ❑ leaching pits number: ® leaching chambers number: 6-Cultec 3050's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool ,.number: ❑ innovative/alternative system Type/name of technology: _ Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach field in good working order and empty at inspection with no visible stain lines. 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 I Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts a=1 Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments 54-56 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is Hyannis MA 02601 11-29-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ...• Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privylocate on site l r( pan). .Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - :a=1 z Title 5 Official Inspection Form :., N Subsurface Sewage Disposal System Form Not for Voluntary Assessments L ,�! 54-56 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is Hyannis MA 02601 11-29-17 required for every y � ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately G j 30 ' J. 3a( 4-.Ll 40 F 6-1 A - & t5ins.doc-rev.6/16 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 54-56 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for every Hyannis MA 02601 11-29-17 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: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: pate ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: + You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. ' s Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 i Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54-56 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for every Hyannis MA 02601 11-29-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i i '.down of Wwnstable- P# " oF� Department of Regulatory Services Public Health Division Date MOM 1 ¢ ems$ n 200,Main Street Hy#nnts MA OZGO1 f �AfTime Fee Pd. Date Scheduled Soil Suitability Assessment for Sewage Dis osal Performed By: R I�1� ti� Witnessed By: LOCATION & GENERAL INFORMfATION / L Location Address'Y/d �yj�C� Owner's Name &H r"t r'AG r►U 6" ' . ^' Address D Assessor's Ma /Patcel: a -7 I Engineer's Name e,,j,rVV to Qjt� " NEW CONSIRU i 10N REPAIR X Telephone# C 3 w, Land Use r_1 � Slopes(%) ' Surface Stones ifo n I �I ft Drinking Water Well • Distances from: open Water Body P ft ossible Wee Area � t P � 16 ft Other Drainage Way ft Pro a Line ! - O -� SKETCH:(street name,dimcnsiods'of lot,exact locations of test holes&perc tests,locate wetlands in proximity t holes) c„ tv r -:j M 5E14 � PUS � �� 1��1 ©% I i i i f .. .. rrtt j Parent material(geologic) lGt,c � Depth to Bedrock Depth to Groundwater. Standing Water in Hole' ' Weeping from Pit Face Estimated Seasonal high Groundwater fl Dt-TERMINATION FOR SEASONAL HIGH WATER TALE Method Used: I- ln. io. Depth to soil mottles: t>< Depth G1b,5erved standing" obs.hole: ; in, groundwater Adjustment ;Depth toiweeping from side of obs.hole: Adj.factor,,,,_ Adj.(iroundwater Level ,,,e Index Well# Reading Date Index Well level - -- PERCOLATION TEST Date: 1 I ��o�9TInie�_.._. Observation I 1 I Time at 9" .L:- --- Hole# Time at 6" -- Depth of Pere v-9 -- I Time(9".611) — Start Pre-soak Time.@ {� - End Pre-soak i Rate MinJlnch • Additional Testing Needed(YIN) • — Site Suitability Assessment: Site Passed X Site Failed; Original:.Public Health Division Observation Hole Data To Be Completed on Back--- ***If ercolalyi�in test is to be conducted within 100' of wetland,.-You tfirst notify the P Barnstable C44servation Division at least one(1)wedk prior to beginning. 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) oil 0 �-33„ G Meg. ��� 2,SY'13 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) 09 /01' A 10 A 4 � IA /0' 33`� C 12 6/x DEEP OBSERVATION HOLE LOG Hole# N14 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cons istency,%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color S011 Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onitnGravel) .t Flood Insurance Rate May: Above 500 year flood boundary No_ Yes , Within 500 year boundary No X Yes Within 100 year flood boundary No k Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material 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 n (date)I have passed the soil evaluator examination approved by the Department of Environ 'ental Protection and that the above analysis was performed by me consistent with the required ing, pertise and experience described in NO CUR 15.017. Signature Date 1 v Q:ISEPTICIPERCFORM.DOC i Town of Barnstable h.- --6 Barnstable . Regulatory Services Department * saatvsrnsi:£, SS 1639. Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO August 27, 2008 Household Finance Corp. 931 Corporate Center Pomona, CA 91769 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 _ The septic system located at 54 & 56 Fresh Holes Road,Hyannis, MA was last inspected on August 5, 2008,by Joseph R. Smith, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" f� under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: f 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; Outlet Tee in main cesspool needs repair. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. CORDER OF THE OARD OF HEALTH as McKean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 7767 Q:\SEPTIC\Letters Septic Inspection Failures\54&56 Fresh Holes.doc pd CX #3,Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' Property Address ��OO Owner OVy_��� 's Name information is ® �(�a � rrequired for '• 1 �,r ll 6 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key _ to move your ���� cursor-do not use the return Name of Ins ector key. mpany Name Company Ad ress N\N City/Town State 9 1 3 ,1 Zip Code Telephone Number License Number is B. Certification -y f I certify that I have personally inspected the sewage disposal system at this addrEWs!and that�he ` information reported below is true, accurate and complete as of the time of the inspection. T6;inspection was performed based on my training and experience in the proper function and ma ntenance_of on site sewage disposal systems. I am a DEP approved system inspector pursuant to:Section 1� 40 of Title 5(310 CMR 15.000).The system,: ` ❑ Passes r (,� Conditionally Passes ❑ Fails � rn ❑ Needs Further Evaluation by the Local Approving Authority 5 o Insp is 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. f t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 • i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments operty Ad reSS P i-X-F Owner Owner's Nameinformation 1 9�,� required forts JJ�Y�'`� `1��� M; , every page. Cityfrown State Zip Code Date of Inspection Bo 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.O v-\\x,� ;,U— r%,, y�L;r CesS eoo\ Yx aS cq y>,- Answer yes, no or not determined (Y, N, ND) in the ❑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. ND Explain: CsrG;v� �eSS$a��� / [observation of sewage backup or break out or high static water level in3the 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): brokenpipe(s)are replaced ❑ obstruction is removed t5insp.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P operty Address Owner Owner's Nam information is 1 v o /\� ®�,�(�` � required for T >o o . every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: Iv ❑ 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 ❑ obstruction is removed ND Explain: 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 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. t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 r ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ( NTc�) Owner Owner's Nam information is B(. s( Uri required for `L`�-� !"\ h every page. Cityfrown State Zip Code Date of Ins ection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Tok Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ('A Any portion of cesspool or privy is within 100 feet of a surface water supply or u� tributary to a surface water supply. t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15A k �!Ik TY-r-� �\O\V-s (.- Property Address HFG� Owner Owner's Namp information is � ��� required for J.� Y-``i� every page. CitylTown State Zip Code Date of In pection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. AE) 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. t5insp.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P operty Address NFc� Owner Own am information is 01 required for �^ � �__ every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? <" ❑ Has the system received normal flows in the previous two week period? F` °�� �'y r ❑ 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 �l 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 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 `C1Uc� �� ❑ approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 5�k T Wo" c Property Address Owner Owner's Na e information is5 �\_\ ,�, 4� required for 1D`�, � every page. Citylrown State Zip Code bat of I spection D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 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 K No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes No Last date of occupancy: Vr ZCF Da e 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: Last date of occupancy/use: Date Other(describe): t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7-75 (Q T Yr6.s1, �- P1ope rty C ress Owner Owner's Name information is �hs�\_� A_ Q f�� -8 0t6 required for ��J 1`� _ld�WI_ U every page. Citylfown State Zip Code Datt of Inspection D. System Information (cont.) General Information Pumping Records: • Source of information: Was system pumped as part of the inspection? ❑ YesK 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 LK 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: Were sewage odors detected when arriving at the site? ❑ Yes No t5insp.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Add s Owner Owner's Nam information is e6 I S" 0% required for "y V"`'i'� b every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron �<40 PVC ❑ other(explain): Distance from private water supply well or suction line: + '50 feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): j 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: GfSS cam\ i �(��0 IK$ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness —1 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? t5insp.doc•03108 Title 5 Official Inspection 0177 Subsurf ce Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P operty Address 1A T-- Owner Owner's Name information is :2 WY'% _\. required for )J w`�.• w\1i �g el every page. CitylTown 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.): TrN1 IGrease Trap(locate on site plan): Depth below grade: 6 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, j 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):. t5insp.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5� �ra✓s Property Address Owner Owner's Name information is required for r1`�'t,°-"� every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons , Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes, ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No ik 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.): I00 R, Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes, ❑ No t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ( Property Address CiAT C-) Owner Owner's Name information is required for I,�' `'`, 5���&L, Mk Q���� ��cal o every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool I ®���` V� 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. rr \ t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Page 12 of 15 I_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l+ ro erty A dress ITT L Owner Owner's Name. information is " � �k' o-�6�� G C required for J> w ✓� l� l every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): %a Number and configuration 1 Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer t 1 �— ;� IL 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.): or�,i•� ram :, ra -SS ��Ur vc�ea:� vA CR-536 v 0- 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.): t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 r Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T-ms'\. Wys (YA Property Address Owner Owner's Name information is ��G1„` `�,�rn�+ ������ G required for IJ V`�- V' 0 ob every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch 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. 3 1 LA O° 132 1 t5insp.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage/Disposal System Form -Not for Voluntary Assessments M 'b� \5k,� roperty A dress Nr L� Owner Owner's Na e information is \\required for G�. G � M� . az( 0 � Skl� every page. City/Town 7 State Zip Code Date of pection D. System Information (cont.) Site Exam: Check Slope t�a Surface water A) ❑ Check cellar D C,,�\�<.( c,' Shallow wells �Y�'L 1 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: "C-y,r (ihYC�yr� e1J�':.,...���w� R,-' .,. Vlep Checked with local excavators, installers-(attach documentation) ,r C ((Accessed USG\S database-explain: \ C You must describe how you established the high ground water elevation: t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable F tHE Tp� o Regulatory Services BARNSTAB e. Thomas F. Geiler,Director MASS °� Public Health Division QED MA'S a Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIMisclaimer Private Septic Inspections.DOC Lf / TOWN 77 OF B�ArRNcS,,��TAABLE LOCATION / �(� �ttJ� �CLJ SEWAGE# 6? —�3 LACE T /�i�' ASSESSOR'S MAP&PARCELo2 � J INSTALLER'S NAME&PHONE NO. LU I�� ONO 2 SEPTIC TANK CAPACITY /,1-00 /000 LEACHING FACILITY:(type) (size) NO.OF BEDROOMS 7 (q4.2) OWNER p d PERMIT DATE: 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 fac ity). feet FURNISHED BY , Q:` J ( e 4 w low _�F j � No. Fee ET THE COMMONWEALTH OF MASSACHUSTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zippy%cation for �Ngoml *p5tem Con0truction Permit PP A lication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑.Com lete System ❑Individual Components . P P�g��- P Y P Location Address or Lot No.!� /z/`�S �(.�1� Owner's Name,Address,and Tel.No.,' eC 0W,9W�fIXAVA;1�9 �l�v Assessor's Map/Parcel A Cd'( s ( �,r.J'AAI Installer's Name,Address,and Tel.No.Lull ) 60P— Designer's Name,Address and Tel.Ni Type of Building: �� WtA Dwelling No.of Bedrooms _I'C L Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided �' gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank7— / Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of ealth. Signe �y O a Application Approved by Application Disapproved by: Date for the following reasons Permit No. Date Issued -r;-•• v . Jam/ V /.C_/ 11 No. .;.��:.:. /' � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes \ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS -appl%cation for 3ioposal �&p.5tem Conotruction Permit Application for a Permit to Construct O Repair O Upgrade( Abandon ❑Complete System ❑Individual Components Location Address or Lot No.J�1 _5K �% 5y yc�_ Owner's Name,Address,and Tel.No..F49viC 0(AAZ�—/-) Assessor's Map/Parcel - I (U r- i!l Installer-'-s N'ame,Address,and Tel.No.tvlwl� m D)A)645Z Designer's Name,Address and Tel.Noo C5 V xy s'Tyd/t _ 49lJGl��1�-/ . Type of Building: (� her), ,)21w W" JN rj Dwelling, No.of Bedrooms L Size sq. ft. Garbage Grinder ( ) 1 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures �c Design Flow(min.required) /„ /) gpd Design flow provided e"r�, gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank r A� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected` ` Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. -- S gne j O e 6 Application Approved by � Da e 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 401�,41�/ at � ,C - � „� — has been c. ructed in accordance with the provisions of and the for Disposal System Construction.Permit No. � dated Installer Designer #bedrooms Approved design flow �(� gpd The issuance of this permit sh 1 not be onstrued as a guarantee that the sys nc n a designed. Date _ Inspecto ——————————=———————————————————————————————-- No. Feezf2 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE MASSACHUSETTS 1 :4 lte;poar 6p!6tem Con5tructton Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( A and n 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 S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permi Date, / � � �Z , Approved by Town of Barnstable 'HE Wit, Regulatory Services Thomas F. Geiler, Director BAMMBLL MAC Public Health� Division pl i63q. awe � Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 5OS-362-464=t Fax: 503-790-6304 Installer & Designer Certification Form Date: D�j Sewaae Permit#, 4d b C Assessor's Nlap\Parcel 29 Z 7y Designer: GF-Vye_,-1 Installer: Address: TO Gf S� Address: = � ✓�' �c�77 � � S, ✓w l 37 On WUAV,1 D% ' vas issued a permit to install a (date) (installer) septic system at Jay Aix, �7� H {-�OL.�`1 7 based on a design drawn by (address) I ► -✓-1A A4 dated S 0$ �( (designer) ' 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation oFthe distribution box andior septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or anv vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. OF MASf''1^ ,A, R,E7'Rom. (Installer's Signature) No: 1140 (Designer's Signature) (Affix Designer's Stamp Here PLEASE RETURN TO BA STABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form 3-264doc No. C Fee /(1� v Entered in computer: �C�U '3C� THE COMMONWEALTH OF MASSACHUSETTS p PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for �agpogar �pgtem Cow5tructiou permit .��.��0 r, �LC R-AD, Application for a P rmit to Consttrruu t/( ) Rep�airc/� Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No.�"J(O ���J170�-C Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 1 /�-�PI� installer's Name,Address,and el.No. ��� Z)iO44/z Designer's Name,Address and Tel.No. S� Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of_Septic Tank Type of S.A.S. 2 ' Cam-. S / _(,ff1L1 e_ Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of HSa Signed ./�/�/� /✓ Date 494? Application Approved by Date 45�7 Ag _ 6 Application Disapproved by: Date for the following reasons Permit No. C� 3<OT Date Issued 6 No. ZF s— G Fee t 'Z p U 8 —, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: l/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIppgi-cation for tigonl *pgtem Cow5truction Permit mi—�to��� L� K �� / " Individual Components 1 Application for a Permit Constru•tt( ) e/'hire(,,)=-Upgrade( ) Abandon( ) ❑ Complete System p Location Address or Lot No.�"75_6 fkF-51--104E 10C Owner's Name,Address,and Tel.No.N CU Assessor'�Map/Parcel GIt I rJ / / �_/Z Installer's Name,Address,and Tel.No.w/L,(-14-�" Designer's Name,Address and Tel.No. �. Type of Building: 1 Dwellingt No.of Bedrooms G Lot Size sq. ft. Garbage Grinder ( ) g Other Type of Building No.of Persons Showers( 1)•Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date r Title Size of.Septic Tank Type of S.A.S. 2 K1. R. Description of Soil a, ` Nature of Repairs or Alterations(Answer when applicable) • r 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. Signed ` � Date / Q f Application Approved by / r G ,od / Date Application Disapproved by: 1 r Date ' IV for the following reasons Permit No. X�T��rs�c�Si".3cLJ� Date Issued —/ - Z- 2 o e 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 at �j 7—�(�, r ���/ �/� ��� has been�constr'uc/t d in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ?_00 dated ZOQC9 Installer �/��GG f�i� Designer ti�/4 #bedrooms v Approved design flow 1 n� gpd The issuance of this permit shall not/be con/s'truuejd.as-a guarantee that the system will fun/2on as designed. Date `' / /// Inspectors ' TNo. G 0 �Ol� Fee DO THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 1=i!5po.5al �§p.5tem Con truction Permit ,l _ _jermission is hereby granted to Construct ( ) Repair (t-1 Upgrade ( ) Abandon ( ) V 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. Provided: Construction must be completed_within three years of the date of this7m . it. /�Date Approved byLei ° i L.000� Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of C?� � ^.� Environmental Protettio , s-. William F.weld Trudy Coxe oowrm ;8ia+ury Arpo Paul Celluccl David B:Strubs ,SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A J/A-l// CERTIFICATION Property Address: Address of Owner. / , 1 C hA,-,o Date of Inspection: ' , `�— L7 6 (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site disposal systems. The system: s _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: e-'L-0 t � _ - � Date: "'z 01 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: A] PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes Indicate ,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,.or tank failure is . . ent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revis 11/03/95) 1 One winter Street a Boston,Massachusetts 02108 a FAX(617)SWI D49 a Telephone(617)292-S500 40 Printed on Recycled Paper 1� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A [[CERTIFICATION(continu e d) ' Property Address: ��— �r� /1�/P S I ij !�I/IS Owner. Date of Inspection: �. )� /NAI.I.Y 9 SESI �� d BJ SYSTEM COND O (contmu" )t9 I? Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 obstruction is removed C] FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ditions exist which require further evaluation by,the Board of Health in order to determine if the system is failing to protect the pu lic health,safety and the environment. 1) S TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. Z) STEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) D NES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND S AND THE ENVIRONMENT: The system has a septic tank and soil absorptionsystem and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or Ion than 5 ppm. 3) (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAST A `CERTIFICATION(continued) , Property Address: v� Owner. Date of Inspection: !� D1 SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LAR E SYSTEM FAILS: e following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Ithe 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) The owner or operator of any such system shall bring the system and facility into fill compliance with the groundwater treatment program requirements f 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for marther information.. (revised 11/03/95) 3 � 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST f Property Address: Owner. A (E h Date of Inspeadon: Check if the following have been done: ping information was requested of the owner,occupant, and Board of Health. __,�One of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. built plans have been obtained and examined. Note if they are not available with N/A. Zhe facility or dwelling was inspected for signs of sewage back-up. _LZ�he system does not receive non-sanitary or industrial waste flow i_he site was inspected for signs of breakout. 'All system components,excluding the Soil Absorption System, have been located on the site. 1 Ae septic tank manholes were uncovered,opened,and the interior of the septic tank,was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _.L�facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surfaoe Disposal System. (revised 11/03/95) 4 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATIONS Property Address: S ���/2 j�ZO/P s 17V �/-t r�� J Owner. Date of Inspection: � - /9-- 9� FLOW CONDITIONS RFBIDENTL4JU Design flow:2�/ O Qallons Number of bedrooms:-4/— Number of current residents: 411A Garbage grinder(,yes or no):_A,0 Laundry connected to system(yes or no)-.,ALA Seasonal use(yes or no): 11 L/� 7 Water meter readings,if available: Last date of occupancy: G 9 COMMERCIAL/INDUSTRLAI. Type of establishment: Design flow:_gallons/day Grease trap present:(yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: - Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ti -'�A System pumped as part of inspection: (_yes or no)_)6��.5 If yea,volume pumped: /-Q-o—o ¢allons Reason for pumping: P/.,/=c X __C,-u&o J',�1 TYPE OF SYSTEM Septic tank/diatr'bution box/soil absorption system Single cesspool 1'�Overilow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: ,3 1 n a lets '/d�v r^a S T Sewage odors detected when arriving at the site: (yea or no) (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) , Property Address: .� 49 ��s /�� S R a Owner. `o� Date of Inspection: SEPPf TANK:_ (locate on ' plan) Depth below Material of on n:_concrete_metal_FR.P_other(ezplain) Dimensions: Sludge depth: Distance from top of dge to bottom of outlet tee or baffle: Scum thickness: Distance from top of to top of outlet tee or baffle: Distance from both of scum to bottom of outlet tee or baffle: Comments: (recommendation for ping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, ) GREASE TRAP: (locate on site plan) Depth below grade: Material of co _concrete_metal_FRP—other(explain) Dimensions: Scum thickness: Distance!from top of to top of outlet tee or baffle: Distance from bottom o scum to bottom of outlet tee or baffle: Comments: (recommendation for ping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, ) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: JD Owner. J� [C n f'y/"o 1!LC 11 h 4M Date of Inspection: T71G T,0R HOLDING TANK:_ (locate site plan) Depth grade: Material of n:_concrete_metal_FRP_other(e:plain) Dimensions: Capacity: one Design flow: ons/day Alarm level: Comments: (condition inlet tee,condition of alarm and float switches,etc.) DISTRIBUTI N BOX:_ (locate on site Ian) Depth of ' level above outlet invert: Comments: (note if level d distribution is equal,evidence of solids carryover,evidence of leakage into or out of boa,etc.) PUMP C ER: (locate on site Ian) Pimps in-or order:(yes.or no) Comments: (note condition of p chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) , Property Adder y- ��¢s le 1_'s /ate Owner. )G`i /'� ��GEC X Date of Inspection: �P / SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan,if possIDle;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: aching pits,number:2 leaching chambers,number:_ leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.) n e E ° G �- 6 ! w so S..b rL. j ! CESSPOOLS:_ (locate on site-plan) � Cal!' L / Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. 3° Depth of scum layer: y °t Dimensions of cesspool: Materials of construction: 6 /n c l 5 it FA i C o d j I Q o 0 Indication of groundwater: Ai O inflow(cesspool must be pumped as part of inspection) z=S Comments:(note condition of soil,signs of hydraulic failure,level'of ponding,condition of vegetation,etc.) o ` l�rv- PRIVY (locate site plan) Mate ' of construction: Dimensions Depth solids: nts:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) / e Property Addrew •• 5-6 Owner. %� ��a� �2 G/�f7 •9/�/j Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' `b ' 3 U \ j i DEPTH TO GROUNDWATER Depth to groundwater. l r feet method of determination or approximation: 614 1-- )S 4.2 ti s /o f L (revised 11/03/95) 9 LOCATION SEWAGE PERMIT NO. VILLAGE I N S T A LLER'S NAME & ADDRESS B UILDER OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED ... �,�y W �� o- �� �_ O � �j r� ,� ,� �` \ ,r C i 11 1.N, + ` F a 1� r-_ �+ ,� _ r,� i . FHB.l...... .:..... �- THE COMMONWEALTH OF MASSACHUSETTS EOARD HEALTH r Application for Ili-spusttl Workii Tomitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (f-�`an Individual Sewage Disposal System t: ... ........... ........................ .. ... .- /,,-oo aattion-Address -- ............... .... .......... _._ . .... d s _2 ........................................ ...... ....... .................... ............ Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (. ) Other—T e of Building a Other—Type g -----•:-•------------------- No. of persons---•-•------...---------..._ Showers ( ) — Cafeteria ( ) QOther fixtures . --------------------------------------•-----------•----......._....-•------•---•. WW Design Flow................................7...........gallons per person per day. Total daily flow............................................gallons.'" W Septic Tank—Liquid capacity............gallons Length._ -----••---•--- Width................ Diameter---------------- Depth................ x Disposal Trench—No. ..............:..... Width.................... Total Length..................... Total leaching area....................sq. ft. 3 Seepage pag Pit No............ ..... Diameter.................... Depth below inlet.......:............ Total leaching area..................sq. ft. ... Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by...................................:....•-••---•---•--.................... Date.:....................................... M Test Pit No. 1................minutes per inch Depth of Test Pit.................._. Depth to ground water........................ -- f?� Test Pit No. 2................minutes per inch Depth of Test Pit.......-...........: Depth to ground water.--..................... ---------------------- ---- -... ---....... -... -... ----------•-----------------•-•-------•------------•-•------•----•----•---••---:----•-------•------ O Description of Soil--------•........................•------------------•---•--......------•--------•-------- ------------------•-----...------•------- x --- - : :.... ---------------------------------•-------.ir ... NaturReaU r Alterations—Answer.-,when applicable4z � .s �3 D<6 ................••-----•--•••-•-•-•---•• Agreement: The undersigned agrees to install the aforedescribed I idual Sewage Disposal System in accordance with the provisions of LITI 5 of the State Sanitary Code— ' h funr- rsig d fur er a ees not place the system in operation until a Certificate of Compliance has be n is ed t bo o ie Signed........ ...... . ...... . .... . ........ -- -- ........................... --•-•---•--Date._.. Application Approved By......................................................... -••- ................................. --Date •.----.....-- Date Application Disapproved for the following reasons:................................................................................................................ .....-•..............••-•-.......•--...-•..-•••-....--•--•--•---.............-•••-....__......•••--...._...----------••-•._.._.......•••---•-•--••-•---•. ..................--•--.... •--•••........ Date PermitNo.......................................................... Issued....................................................... Date F>�s.............................. �0 THE COMMONWEALTH OF MASSACHUlSCTTS BOARD OF HEALTH f � Application for Uiupoiittl lgorkii Tonstrurtion rrrutit Application is hereby made for a Permit to Construct ( ) or Repair (1- an Individual Sewage Disposal � System at: .. .. '�i .... r 1 �� ` Location Address or LotfNo. ------�----• —c� � .._�.l...__.._,. / r Address .............. .......................................... ........................................ � �/� Installer Address Type of Building Size Lot............................Sq. feet ., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther —Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ---------------____----------------_______•----- W Design Flow............................................gallons per person per day. Total daily flow............................_...............gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.............._..... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area................... ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date.:....................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water............. . 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 .... •------------------------------- •--------------------------- •-------- _------------------ •------- ----------------------------------- --------- •------ -••••- 0 Description of Soil........................................................................................................................................................................ U ---------------- ------------------- •--------- --------------------------------- ._...------------ •---------•-----------_----.--•-- -------- -__-------- ......:------•-•--•-------•----_...... 11, x --------------------•-------•••........................ --••-•-•...•-•---••..._.. U Nature of Repair for Alterations—Answer;when applicable�-���!�`��r�.��!��!�'�r_^"___.___�"��'�'. A01"__.... Agreement The undersigned agrees to install the aforedescribed Ind vidual Sewage Disposal System in accordance with the provisions of TITL 5 of the State Sanitary Code—iI'lle undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued y th,'board of'he�h: Signed :_'"�'' �-......... -., ............................ ...... ApplicationApproved By.................................................................................................. Date Application Disapproved for the following reasons--------------------•-------------------------.....------------------------------•--•--••••--••---•-••.......... ...................•-------...---•-•---...---------...-•--•-..................--•---•--•,=----..'....:..-•-=----------.....------------....................................•----... ......-•--••• Date J PermitNo......................................................... Issued....................................................... Date f -------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '.�e-11 ..........OF........,....... ... .............. (9rdifiratr of (Eaautplittnrr THIS IS TO CERTI,,FyrThat the Ind'vidual° Sewage Disposal System constructed ( ) or Repaired (L-•)-�" by 'e�'c "'.'• .i /.. . ._ �__" 5= ' ----------...-------•-------......---------------•--------_...............................•------------- at... //+...._.._ .rF. -- ---- -•---- ---• -- - has been installed in accordance with the provisions of ThI'IE' 5-of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.X�rP�?-._�-'..�`5_.......... dated_............................................. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION ATISFACTORY. } DATE.............. 11 - �---•----•---.....--••---------...------..... Inspector.................................... THE COMMONWEALTH OF MASSACHUSETTS p / ! BOARD OF HEALTH ~ O��(J(C�a ...........................................OF..................................................................................... N0......................... FEE........................ Diupoutt14F urkuu,,�at� r�ttr# on rrtni# Permission is hereby granted.....:�� _���-L G"'WZ........................................................................ . - to at No Construct �� pair ( �-) an/.Individual Sewage Disposal System or Re 'S .ala` fib '�G % tS d ................................................ -••-•---.......-------••---....----------------•-•-•-----------•------••-•-•--- Street as shown on the application for Disposal Works Construction Pie ---==Dated.......................................... -------•----•--------=---•.................•----•-----------------.------------......-•-•-•---........_ /t/. Board of Health DATE---.-/_..--✓ "7 TOWN 1LOT VIL jGl/Iy�c;sSESSOR'SMAP&. IA INSTPiLL.E 'S D AIM lk Pi IOI�B I`IO st'Ic TI � AcaT )ILOO1;m �3YJIILOFA cpl C.W1�E- PEIttTI31'I + OO1�PC..IP► It ATE on., 13sitvreen�tie , NlaxnnumAil' i G�au�adwatet' it�ie�atllcl3ottotnatX.aachirc E�nei6ty 1t�eet Pbtvec�Wat4r Su ! WeXI tuitl I, ihhit►g IxacditYy���;IIs s:xist I? ,y t an agtsr cr wlttur< (If)feet of losscua �Grty) ; Ecl�s�clfi W�tXsmd said lLeAclhtfl�r�acillty�Yf any wetlands exist ;: s+ 9fasst 3160 0 6. a �J cry Uo o � v; Q v i t I LEGEND a „inad, 0 ► 1 � � g PROPOSED CONTOUR ML ,,..�-•�--"� I, w FIE PROPOSED SPOT GRADE' EXISTING CONTOUR i + 96.52 EXISTING SPOT GRADE naSQ 1 . r Existing Cesspools W= EXISTING WATER SERVICE See Note 10 TEST PIT 9_ r _ l i 1 � - _ 126 87 r t . O f 6• , 50 l ----------- - �- - _�lnsp. port so / 52. --- LOCUS MAP N.T.S. �� P - - ). \ o GENERAL NOTES: y i ALL CHANGES`TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. N N i 2. ALL WORK AND MATERIALS.SHALL CONFORM TO THE REQUIREMENTS I /RE /' OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE / ` TH-1 _ LOCAL RULES AND REGULATIONS. CO TH-2 ���� j 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR �ST / TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING !� FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN , j $rO ENGINEER BEFORE CONSTRUCTION CONTINUES. Top // \0� i% 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. OF ! 1 / 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 1 p �• /�/ / • THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF S O ' p / � O �/ /" HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. R SUPPLY PROVIDED OWN WATER �, BENCH MARK 8. ALL AREAS REAS DISTURBED DURNGTCONSTRUCTION SHALL BE RESTORED / PAINT SPOT ON TO A CONDITION AGREED UPON 'BETWEEN OWNER AND CONTRACTOR. 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY Q I CONCRETE STEP O THE LOCATION OF ALL UNDERGROUND UTILITIES' PRIOR TO BEGINNING / ` i. \ I t40- O T 6 i ELEVATION. = 5O. 58 CONSTRUCTION. G / 1 EXISTING P V F Q' 0. E S CESSPOOLS TO BE PUMPED AND REMOVED FILL WITH CLEAN MED. SAND �. — , . ��F p \_ AREA — 8657 sf� B.4R.NSTABLE CIS DATUM 1 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 31 43 t "�fie_M 1�� a {� I 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 1 13. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING 7S 14. ALL PIPING TO BE 4" SCH 40 0 1/8"/FT.(UNLESS SPECIFIED OTHERWISE) 9 rt5.76 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW Tt FOR THE USE OF A GARBAGE GRINDER B GE G DER 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING 17. PROPERTY IS NOT LOCATED IN A ZONE OF CONTRIBUTION. OF M,yss9�yG 0 O R,� /�• No. 1140 ' PROPOSED SEPTIC SYSTEM UPGRADE PLAN Silo 54 & 56 FRESH HOLES ROAD, HYANNIS, -MA NI Tow �k Prepared for: Mike Dedecko SURVEY REFERENCE: MAP. 292 Engineering b : Surveying b : SCALE DRAWN 9' 9 Y Y 9 Y JOB. NO. LOT:174 DARREAIM.MEYER,R.S. Eco-Tech Environmental 1"=20' DMM PLAN OF LAND BY BEARSE & KELLOGG, CIVIL ENGINEERS .l V PO BOX LCPA 141213 (508) 364-0894 DATED: MAY 1, 1954 i EAST SANDWICH,MA 02597. GATE: CHECKED SHEET NO. soe ssz-2s22 1 1/15/08 DMM 1 of 2 i ELEV. TOP FOUNDATION NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS (Existing Slab) INSTALL RISERS W/IN 6' OF FINISH GRADE A = 51.04 F.G.EL: 50.75 F.G. EL: 50.0 FINISH GRADE= 50.0 . : F.G.EL: 50.0 �- MAINTAIN 2% MIN SLOPE OVER LEACHING AREA BRING ALL COVERS TO GRADE I { 6" INSPECTION PORT W/IN 6" OF FINISH GRADE :4 ,4 .a, 10„ . 14 " TEE'S ARE TO BE 10'I • o 0 0 0 0 0 0 0 0 0 0 0 q INV. 4" SCH 40 PVC INV. EL. .84 EL.= 47.50 TEE'S ARE TO BE 14 .6 1 __ S= 1% (MIN.) .� INV. 4' SCH 40 PVC INV. GAS BAFFLE 59 J EL.= 47.25 INV o o e o 0 0 0 0 0 0 0 0 `.... BAF LE t EL.= 4705 EL.= 46.95 EXIST. OUTLETS PROPOSED 1,500 GALLON SEPTIC TANK 0 m 0 0 0 0 0 0 0 0 0 0 A EL: 48.54 PROPOSED 1,000 GALLON SEPTIC TANK PROPOSED DB-3 EL: 4$.54 IH-10 DISTRIBUTION BOX I I 52. 7 NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING l PIPE INVERTS PRIOR TO CONSTRUCTION 2) D-BOX SHALL BE SET LEVEL AND TRUE TO 7 fL7 ?Fes' 9" MIN. GRADE ON A MECHANICALL COMPACTED SIX PER T1 TLE 5 INCH CRUSHED STONE BASE, AS SPECIFIED IN Qf SAS 310 CMR 15.221(2) BREAKOUT EL. = 47.35 ARM. 3) INSTALL INLET & OUTLET TEES AS REQUIRED INV. ELEV.=46.85 MEYER 314•- 1-1/r 24" 30.5" No. 1140 "' 00tt"WASNn srm o SEPTIC SYSTEM PROFILE BOTTOM EL.= 44.85 IN tER1 ' GIS1E�' -48" 50" 48 S4NI tAR��'� } I I II SEPARATION 5.65 v-r. SOIL ABSORPTION SYSTEM (SECTION) INFILTRATOR 3050 SPECIFICATIONS BOTTOM OF TH-1 EL: 39.2 INFILTRATOR 3050 UNIT (1120 LOADING) SOIL LOGS DESIGN 'CRITERIA 6 NUMBER OF BEDROOMS: 6 BEDROOOM (Property not in Zone II) DATE: NOVEMBER 14, 2008 SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) SOIL EVALUATOR: DARREN MEYER, R.S., CSE DESIGN PERCOLATION RATE: <2 MIN/IN 0 WITNESS: DONNA MIORANDI DAILY FLOW: 110 G.P.D. DESIGN FLOW: 660 G.P.D. HEALTH AGENT GARBAGE GRINDER: NO (not designed for garbage grinder) I INLET(OPEN)D Elev. TH- 1 Depth Elev. TH-2 Depth SEPTIC TANK: 660_� gpd x 2 = 1,320 gpd USE (2) TANKS (1,500/1,000) IN SERIES 49.70 0" + 49.70 A LOAMY SAND A O" (660) = 891.9 S.F. 10YR 4/1 , LOAAMRY AND LEACHING AREA REQUIRED: Y 74 4.9'D[A ACCESS PORT FOR INSPECAON. 48.87 B 10" 48.87 B 10" USE THREE (6) INFILTRATOR 3050 UNITS WITH 4 FT. STONE ON LOAMY SAND > • I LOAMY SAND ALL SIDES 52.7 L x 12.16' W x 2 D 10YR s/8 10YR 6/8 BOTTOM AREA: 52.7 x 12.16 = 640.8 SF 46.95 C1 33" I 46.95 Ct 33" SIDE AREA: (52.7 + 12.16) X 2 X 2 = 259.4 SF TOTAL SQUARE FEET PROVIDED = 900.2 vs. 891.9 REQ'D o ° o ° o DESIGN FLOW PROVIDED: 0.74(900.2 S.F.) = 666.14 G.P.D. vs. 660 G.P.D. req'd PERC ®45.25 MEDIUM MEDIUM PROPOSED SEPTIC SYSTEM UPGRADE PLAN SAND SAND 54 & 56 FRESH HOLES ROAD, HYANNIS MA INFILTRATOR 3050 2.5Y7/3 2.sY7/3 , NOMINAL CHAMBER SPECIFICATIONS Prepared for: Mike Dedecko Engineering by: Surveying by: . SCALE DRAWN JOB. NO. 39.2 126" 39.2 126" DARRENM.MEYER,R.S. Eco-Tech Enviroomenw N.T.S. DMM SIZE (W X H X L) 5 1" X 30" X 85.4" PO BOX 981 (508) 364-0894 WEIGHT 80.0 LBS. PERC RATE <2 MIN/IN. ("C" HORIZON) PERC RATE <2 MIN/IN. ("C" HORIZON) EASTsAwmcH mAo25s7 DATE CHECKED SHEET NO. NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED 508-3622922 11/15/08 DMM 2 Of 2 f