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HomeMy WebLinkAbout0058 ORR'S AVENUE - Health 58 Orr's Avenue, Hyannis A= f, _llr J l i i o Commonwealth of Massachusetts o'Z°11 l Title 5 Official Inspection Form .� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 58 Orr's Ave. H ant is, MA 02601 - 3' Property Address r Jennifer Lozada 24 Lowell Rd. Owner Owner's Name information is tj required for every Concord MA 01742 3/1/2019 page. City/Town N.2. State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not,be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms p ' ( on the computer, 8aD use only the tab Paul C. Martin key to move your Name of Inspector cursor-do not . use the return Cape Cod Septic Services Inc. key. . Company Name 350 Main St. ,& Company Address West Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance.of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2• ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails. pector's Signature Date 19 Date The system inspector shall submit a copy of this inspection report to the Approving Authority.(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate_ . regional office of the DEP. The original form should be sent to the system owner.and copies sent to; the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 1 of is 1 Commonwealth of Massachusetts I Title 5' Official Inspection 0 Subsurface Sewage Disposal System F -Not for o Form Form Voluntary Assessments •� 58 Orr's Ave. Hyannis, MA 02601 Property Address Owner Jennifer Lozada 24 Lowell Rd.information is Owner's Name required for every Concord MA 01742 page. City/I own State 3/1%2019 -Code Code Date of Inspection C. inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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. Comments: System in working condition. 2) System Conditionally Passes: 0 One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than,20 years old is available. Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page,2 of 18 Commonwealth of Massachusetts _ 1? Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Orr's Ave. Hyannis, MA 02601 Property Address Jennifer Lozada 24 Lowell Rd. Owner Owner's Name information is required for every Concord MA 01742 3/1/2019 page. City/Town State Zip Code Date of Inspection C. Inspection-Summary (cont.) 2) System Conditionally Passes (cont.): Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is.removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a.year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the.Board of Health): ❑ broken pipe(s).are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR '15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 commonwealth of Massachusetts Title 5 . Official Inspection For �1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments�, y t, 58 Orr's Ave. Hyannis, MA 02601 Property Address Jennifer Lozada 24 Lowell Rd. Owner Owner's Name information is required for every Concord MA 01742 3/1/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a 'septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia.nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each'of the following for_all inspections:dons• 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �u 58 Orr's Ave. Hyannis, MA 02601 Property Address Jennifer Lozada 24 Lowell Rd. Owner Owner's Name information is . required for every Concord MA 01742 3/1/2019 page. City/Town State Zip Code Date of Inspection. . C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑. ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in.cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOTdue 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the.analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health'to determine what will be necessary to,correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.1/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts I Title 5 Official Inspection_ Form Subsurface Sewage.Disposal System Form -Not for VoluntaryAssessments,sments'. L 58 Orr's Ave. Hyannis, MA 02601 Property Address Jennifer Lozada 24 Lowell Rd: Owner Owner's Name information is required for every Concord page. MA 01742 3/1/2019 City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system..has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no"for each of the following.for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ 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 is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments sessments 58 Orr's Ave. Hyannis, MA 02601 Property Address Jennifer Lozada 24 Lowell Rd. Owner Owner's Name information is required for every Concord MA 01742 3/1/2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 110x3= Description: 330gpd Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected?. ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 2017=76gpd Detail: 2018=82 pd Sump pump? ❑ Yes No Last date of occupancy: Unknown Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts lip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �V 58 Orr's Ave. Hyannis, MA 02601 Property Address Jennifer Lozada 24 Lowell Rd. Owner Owner's Name information is required for every Concord MA 01742 3/1/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based. on 310 CMR 16.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? El Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3.• Pumping Records: Source of information: No records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts 11? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - is Y Not for V olunta Assessments ts. V 58 On's Ave. Hyannis,MA 02601 Property Address Jennifer Lozada 24 Lowell Rd. Owner Owner's Name information is required for every Concord MA 01742 3/1/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool. ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and.a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP.approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® .No 5. Building.Sewer(locate on site plan): Depth below grade: 2611 feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: +10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line was checked with sewer camera and found to be clean, properly pitched with no sign of root intrusion. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts - 0. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Orr's Ave. H annis, MA 02601 Property Address Jennifer Lozada 24 Lowell Rd. Owner information is Owner's Name - required for every Concord . MA 01742 3/1/2019 page. City/Town State i Code P Date of Inspection. D. System information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 18" feet Material of construction: ®concrete ❑ metal ❑fiberglass 9 ❑polyethylene El 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: 1000Gal Sludge depth: 3" 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? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000Gal tank in good condition PVC tees in place. Tank at normal operating level. Covers 6" below grade. --------------- t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 ., Commonwealth of Massachusetts -- ►1��. Title 50 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Orr's Ave. Hyannis, MA 02601 Property Address Jennifer Lozada 24 Lowell Rd. Owner Owner's Name information is required for every Concord MA 01742 3/1/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth.below grade: feet Material.of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be'pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of.Massachusetts - , Title 5 Official Inspection Form 1`I Subsurface Sewage Disposal System -Not for Voluntary ry Assessments 58 Orr's Ave. Hyannis, MA 02601 Property Address Jennifer Lozada 24 Lowell Rd. Owner Owner's Name information is required for every Concord MA 01742 3/1/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 011 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minim al solids carr . o ryover. N sign of overloading or hydraulic failure. Cover 28"below grade. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ip Title 5. Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Orr's Ave. Hyannis, MA 02601 u Property Address Jennifer Lozada 24 Lowell Rd. Owner Owner's Name information is required for every Concord MA 01742 3/1/2019 page. City/Town State zip Code Date of inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan;.excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5-Infiltrators ❑ leaching galleries number: ❑ leaching-trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form ii; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Orr's Ave. Hyannis, MA 02601 Property Address Jennifer Lozada 24 Lowell Rd. Owner Owner's Name information is Concord required for every MA 01742 3/1/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 5-Infiltrators with stone. No standing effluent in chambers dutring inspection. No evident stain. No sign of overloading or hydraulic failure. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Orr's Ave. Hyannis, MA 02601 Property Address Jennifer Lozada 24 Lowell Rd. Owner Owner's Name information is required for every Concord MA 01742 3/1/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments ssments 58 Orr's Ave. Hyannis, MA 02601 Property Address Jennifer Lozada 24 Lowell Rd. Owner Owner s Name information is required for every Concord MA 01742 3/1/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection, Form FSubsurface Sewage Disposal,System Form -Not for Voluntary Assessments V 58 Orr's Ave. H annis, MA 02601 Property Address Jennifer Lozada 24 Lowell Rd. Owner OwneYs Name information is required for every Concord MA 01742 3/1/2019. page. Cit Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +10' feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high groundwater elevation: Hand auger did not encounter water at 10'. Max bottom of leaching is 5'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments.essments 58 Orr's Ave: Hyannis, MA 62601 Property Address Jennifer Lozada 24 Lowell Rd. Owner Owner s Name information is required for every Concord MA 01742 3/1/2019 page. City/Town State. Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 - a auUVJJlllb' 1"�J-jj Ull 1. LarUS - Page l of 2 TOWN OF BARNSTABLE LOCATION Q rr� VlL SIC AGE SP VILLAGEA ' ASSESSOR'S MAP&PARCEL "*W NAME&PHONE NO. C� n►tia(1 9 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ;� !t {j?(avor S (size) NO,OF BEDROOMS h OWNER�n'ICny �o---r�_ PERMIT DATE: C-qA4>gbD Separation Distance Between the: 9 d .... Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility " Private Water Supply Wcll and LeachingFacility --_Fee t site or within 200 feet of leaching facility �f any wells exist on Edge of Wetland and Leach' Facility(if any wetlands exist within --------Feet 300 feet ofleac ' facility)' FURNIS14ED BY — --.__Feet - ... ... ---'—•.-—4., � � _�---�.. "----^— etc.., ;P � �„_.._._.,,.,•+:. _^.- 25 25 49 24 JJ r`Jr`\'\tJJ J r J r J ♦ J J ri` . ater ervice Orr's A ve http://web.townofbarnstable.us/Departments/Assessing/Property Values/HMdisnlay.a.sn?m t ioi1)ni 0 1. Y No. / l A Fee f�0_V THE COMMONWEALTH 4 MASSACHUSETTS Entered in computer: V Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 3ppfication for M.5paaf *pttem Construction Permit Application for a Permit to Construct( )Repair(.X Upgrade( )Abandon( ) ❑Complete System tdividual Components Location Address or Lot No. • *6g ©QJ 15 Ai&WE Owner's Name,Address and Tel.No. ,4,e `MA f3NAharty 1`�%orrous Assessor's Map/Parcel a g i I l q q J(4*A 6 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 'Roder V;SktCV__ EIJQQ G,res• . 5og Z4fo-Zl�ob 39 - 4lacv Type of Building: Dwelling No. of Bedrooms Lot Size �Zi�" sq.ft. Garbage Grinder(alo � ! Other Type of Building Ne w No. of Persons a Showers( vj Cafeteria( V) Other Fixtures k--Tc,�4p,) G)rt, L�vr►D4�1� Design Flow eJ30 gallons per day. Calculated daily flow 333.9® gallons. Plan Date OS Number of sheets I Revision Date Title ` Q4> y5 %t� 11 bec ci�F Size of Septic Tank �[t5T I 1 t )�D 4',C 1 e>n-Tp w Type of S.A.S. S /N 1=i crtzA-TOs Description of Soil: Q � pN ��`X 3}•a5� X.g3 T2fei{ Nature of Repairs or Alterations(Answer when applicable) 7i�a_Qac A-b �Aclfl 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 Environme -a Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by,A9k Bard of Heal .t Signed Date I !� Application Approved by Date Application Disapproved for the following reasons Permit No. 6405 44 Date Issued11*1-11 1 No. Fee ^ ' Entered in computer: THE �MMONWEALTHJC!PMASSACHUSETTS p .Ne q Yes PUBLIC HEALTH DIVISION - TOWN OF BARN�STABLES rMASSACHUSETTS 2(ppfication for Mt!5po5af 6pgtem Cougtruction Permit Application for a Permit to Construct( )Repair(><)Upgrade( )Abandon( ) ❑Complete System ',individual Components k� Location Address or Lot No. (}M'S f4VEAJVC Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ar¢. SHAY EnIJ. Sacs• 5 o S 2.4(q-ZBob Type of Building: Dwelling No.of Bedrooms ` Lot Size Z Z, sq.ft. Garbage Grinder Ojlhv -- Other Type of Building nlor►c. No.of Persons Showers(r/) Cafeteria - Other Fixtures slr3k; Design Flow ?>?1)0 gallons per day. Calculated daily flow .917 gallons. ` Plan Date 8S Number of sheets Revision Date Title., Size of Septic Tank ��4c-1- t .i::On C,rAl en sort Type of S.A.S. �C ial G�► 'a-t[�'pT�25 Description:"of Soil P e -k-n j~*s cr\ !7)'X 3�.�5� X.3a" r2£n1CN Nature of Rel-'rs or Alterations(Answer when applicable) A:.' . Date last inspected: ' .. ' Agreement: The undigffed 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 Environme 41'Code and not to place the system in operation•until a Certifi- " cate of Compliance has been issued by this Board of Healtie. Signed 9 / � Date Z !JS ± Application Approved by _ /1?9 Date 1 Z Application Disapproved for the following reasons / Permit No. E^3_U 5 4JA — Date Issued - THE COMMONWEALTH OF MASSACHUSETTS' " BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CER I)", that the On-site Sewage Disposal System Constructed( )Repaired( ) Upgraded( ) Abandoned( )by , k: at `?, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 1� 44 dated I " Installer \�� �.rQ-✓� Designer . The issuance of this permit shall not be construed as a guarantee that the stem o i f1R n as designed. Date �l 1� ` 5 Inspecto� l _..�. - ————— [---——————————————————————-----— — — - •; No. —/ p! Fee CJCJ- = ry THE COMMONWEALTH OF MASSACHUSETTS Lr,y. rt PUBLIC HEALTH DIVISION . BARNSTABLE., MASSACHUSETTS R Migogal *pgtem Con!9truction Permit Permission is hereby granted to Construct( )Repair(,__ )Upgrade( )Abandon( ) System located at Sc� rrS e fMG�n=, S t - a F 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 this permit. Date:_ 2 OS Approved byre-'h- Town of Barnstable °F1HE r° Regulatoty Services Thomas F. Geiler, Director • umgrwam ' � Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&.Designer Certification Form Date: I �J Designer: Shay Environmental Services, Inc. Installer: Address: P.O. Box 627 Address: T East Falmouth, MA 02536 6� , On q 10^tAus 5Vox- was issued a permit to install a ate) staller) septic system at n i S based on a design drawn by (address) Shay Environmental Services, Inc. dated QS (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or 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 any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified built by dessimIner to follow. �N OF�LyS s CARMEN (Insta er's nature) 0 E. SHAY N No. '1181 GJSTE��O SANITAR\P� (Des><g r s ignature) ' (Affix De > tamp Here) PLEASE RETURN TO BARNSTAB 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 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM hereby certify that the engineered plan signed by me dated f3 O S concerning the property,located at d B Qe-Q S Ac1F, E--sj pAnSiS meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are.no.commercial or business uses.associated with the:dwelling. • The soil is.classified as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or.may conduct deep test holes and percolation tests.at the site without a health agent present. 0 There is no.increase in flow and/or change in use proposed • There are no variances requested or needed. • The.bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the. Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 3 B) G.W.Elevation +adjustment for high G.W. 3_ca _ DIFFERENCE BETWEEN A and B . SIGNED : DATE: &S 0 NOTICE Based upon the above information; a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. �iW-aa Cc� (3 4 gASeptic\percexemp.doc r 4 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments w 58 Orr's Avenue — Property Address NMG Development Corp. — Owner Owner's Name information is Hyannis MA 02601 July 29 2009 — required for State Zip Code Date of Inspection every page. Cityrrown Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the / computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell — cursor-do not Name of Inspector key the return Septic Inspection Services Co. — Y Company Name 189 Cammett Road — company Address Marstons Mills MA 02648 reun Cityrrown State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification I certifythat I have personally inspected the sewage disposal system at this address and that the cn 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 N sewage:disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of ca U- t Title 5(34FO CMR 15.000). The system: ® Passes ElConditionally Passes ❑ Fails C> ❑ Needs Further Evaluation by the Local Approving Authority V� July 29 2009 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Boards 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. U� ****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. 09-138 NMG Dev..doc•08t06 Title 5 Official Inspection Form:A.g'e Disposal Sys am(.g 'of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 58 Orr's Avenue Property Address NMG Development Corp. Owner Owner's Name information is Hy annis MA 02601 July 29, 2009 required for — every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, leaching system had no standing water at time of inspection. 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. 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: ❑ 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 ❑ obstruction Is removed 09-138 NMG Dev..doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Orr's Avenue — Property Address NMG Development Corp. _ Owner Owner's Name information is H annis MA 02601 July 29, 2009 required for y — 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: ❑ 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. 09-138 NMG Dev..doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Orr's Avenue _ Property Address NMG,Development Corp. _ Owner Owner's Name information is Hyannis MA 02601 Jul 29, 2009 required for y y every page. Cityrrown State Zip Code Date of Inspection 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_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 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. 09-138 NMG Dev..doc-08/06 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 58 Orr's Avenue _ Property Address NMG Development Corp. _ Owner Owner's Name information is required for y H annis MA 02601 July 29, 2009 - every page. CityrFown State Zip Code Date of Inspection 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. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 09.138 NMG Dev..doc•08/06 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 M 58 Orr's Avenue _ Property Address NMG Development Corp. _ Owner Owner's Name information is Hyannis MA 02601 Jul 29, 2009 required for y y every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)) 09-138 NMG Dev..doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 58 Orr's Avenue _ Property Address NMG Development Corp. _ Owner Owner's Name information is Hyannis MA 02601 Jul 29 2009 required for y y � — every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 — Number of current residents: 0 — Does residence have a garbage grinder? Yes INo 9 9 9 ❑ Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 2-3 weeks prior to inpsection. 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): — 09-138 NMG Dev..doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Orr's Avenue Property Address NMG Development Corp. Owner Owner's Name information is Hyannis MA 02601 Jul 29, 2009 required for y y — every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None — 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) El maintenance technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Leaching system installed 9/12/05 Were sewage odors detected when arriving at the site? ❑ Yes ® No 09-138 NMG Dev..doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 0f 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 58 Orr's Avenue Property Address NMG Development Corp. Owner Owner's Name information is H annis MA 02601 Jul required for y y 29, 2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' _ Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 2' _ 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: 8.5' long x 5.2'wide- 1000 gal. — 3" Sludge depth: — Distance from top of sludge to bottom of outlet tee or baffle 27" — 2„ 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 12 — How were dimensions determined? Measured 09-138 NMG Dev Aoc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Orr's Avenue _ Property Address NMG Development Corp. — Owner Owner's Name information is Hyannis MA 02601 Jul 29, 2009 required for y y every page. Cityrrown 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.): Liquid level was found at bottom of outlet invert, tees are intact and clear. Tank is not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 09-138 NMG Dev..doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Orr's Avenue Property Address NMG Development Corp. Owner Owner's Name information is Hyannis MA 02601 Jul 29 2009 required for Y Y every page. Cityrrown State Zip Code Date of Inspection I D. System Information (cont.) Tight or Holding Tank (cont.) J 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 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.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09-138 NMG Dev..doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Orr's Avenue _ Property Address NMG Development Corp. Owner Owner's Name information is Y required for y H annis MA 02601 Jul 29, 2009 every page. Cityrrown 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: Five Infiltrator:_ ❑ 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.): Infiltrators have no standing water or evidence of surcharge. _ J 09-138 NMG Dev..doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Orr's Avenue Property Address NMG Development Corp. Owner Owner's Name information is Hyannis MA 02601 Jul 29, 2009 required for y Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — Depth—top of liquid to inlet invert — Depth of solids layer — Depth of scum layer — Dimensions of cesspool Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 09-138 NMG Dev..doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Orr's Avenue Property Address NMG Development Corp. Owner Owner's Name _._.__....__.._...--------------------------------- information is Hyannis MA 02601 Jul 29, 2009 required for Y --.—.__-- Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including tied) to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ........................................ 25 25 24 49 \ \ \ \ \ \ \ \ \ \ \ \ \ Water Service Orr"s Ave Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Orr's Avenue Property Address NMG Development Corp. Owner Owner's Name information is Hyannis MA 02601 Jul required for Y _ y 29, 2009 every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 20 and topo map shows property above el. 30 09-138 NMG Dev..doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Commonwealth of Massachusetts a U W Title 5 Official Inspection Form DIN- Subsurface `�� Sewage Disposal System Form - Not for Voluntary Assessments cM 58 Orr's Ave. Property Address Raphael Nunes Owner Owner's Name r information is Hyannis Ma. 02601 10/1/2007 required for y 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not use the return Name of Inspector key. Capewide Enterprises,LLC Q 2 CA C1 Company Name r� P.O.Box 763 i Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site . sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: � t,4 ® Passes ❑ Conditionally Passes ❑ Failst , ❑ Needs Further Evaluation by the Local Approving Authority ° , co D, 10/1/2007 Inspector's Signature Date ` The system inspector shall submit a copy of this inspection report to the Approving Authority(Board. of Health or.DEP)within 30 days of completing this inspection. If the system is a s ared 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. 58 ores ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts N W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 58 Orr's Ave. Property Address Raphael Nunes Owner Owner's Name information is Hyannis Ma. 02601 10/1/2007 required for y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System,Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic.system is in proper working order at the present time. 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. 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: ❑ 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 ❑ obstruction is removed 58 orr's ave.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 I ' Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments ^M 58 Orr's Ave. Property Address Raphael Nunes Owner Owner's Name information is required for H annis Ma. 02601 10/1/2007 y 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: . ❑ 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. 58 orr's ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15: ' Commonwealth of Massachusetts Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 58 Orr's Ave. Property Address Raphael Nunes .Owner Owner's Name information is required for Hyannis Ma. 02601 10/1/2007_ every page. City/Town State Zip Code Date of Inspection 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: I D) System Failure Criteria Applicable to All Systems: l 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 El ® 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 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. 58 orrs ave.•08/06 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 ^M 58 Orr's Ave. Property Address Raphael Nunes Owner Owner's Name information is required for H annis Ma. 02601 10/1/2007 y every page. City/Town State Zip Code Date of Inspection 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. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive.area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 58 ores ave.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 ' Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Orr's Ave. Property Address Raphael Nunes Owner Owner's Name information is Hyannis Ma. 02601 10/1/2007 required for y � 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 I ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage backup? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ®, ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 58 ores ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 58 Orr's Ave. Property Address Raphael Nunes Owner Owner's Name information is required for Hyannis Ma. 02601 10/1/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 -Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usa e d NA 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No f Last date of occupancy: ate/2007 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): 58 ores ave.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 58 Orr's Ave. Property Address Raphael Nunes - Owner Owner's Name information is Hyannis Ma. 02601 10/1/2007 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information ' Pumping Records: Source of information: Capewide Enterprises,LLC Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: _ 1000 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: New Leaching installed 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No 58 orr's ave.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 58 Orr's Ave. Property Address Raphael Nunes Owner Owner's Name information is required for Hyannis Ma. 02601 10/1/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 14"feet Material of construction: I ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10� Comments (on condition of joints, venting, evidence of leakage, etc.): Joints,appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 18.1 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: 8'6"x4'10"x57' Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle na Scum thickness 0 Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? tank pumped 58 ores ave.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 f ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Orr's Ave. Property Address Raphael Nunes Owner Owner's Name information is required for Hyannis Ma. 02601 10/1/2007 every 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.): Pump septic tank every 2-3 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 58 orrs ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 58 Orr's Ave. Property Address Raphael Nunes Owner Owner's Name information is required for Hyannis Ma. 02601 10/1/2007 every page. City/Town 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No,evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 58 ores ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 58 Orr's Ave. Property Address Raphael Nunes Owner Owner's Name information is `required for Hyannis Ma. 02601 10/1/2007 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: 5-HC Infiltrators. ❑ 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.): ponding or damp soil.Sandy dry soil.No signs of hydraulic failure.No 58 orr's ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 ' Commonwealth of Massachusetts ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 58 Orr's Ave. Property Address Raphael Nunes Owner Owner's Name information is required for Hyannis Ma. 02601 10/1/2007 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): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I � 58 orfs ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Orr's Ave. Property Address Raphael Nunes Owner Owner's Name information is required for Hyannis Ma. 02601 10/1/2007 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. 1 -------------- + � . 1 r + ♦- ---- --- � � 58 on s ave.•08/06 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 58 Orr's Ave. Property Address Raphael Nunes Owner Owner's Name information is required for y H annis Ma. 02601 10/1/2007 every 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 ground water: Bottom of leaching 20' 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: 2005 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used:Gaherty& Miller Model 12/16/94 ground water elevations. Used: USGS Observation Well Data June 1992. Used:Technical Bulletin 92-000-01 Plate#2 annual ranges of ground water elevations. 58 ores ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 f . Town of Barnstable Regulatory Services STABS ; Thomas F. Geiler,Director BARN,eTE1639.D3�p Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 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/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s 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 Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. r OF THE 1p� Town of Barnstable BAMSTABLE, 9 MASS. $ Regulatory Services �p!1639. a,� Thomas F. Geiler, Director fD MP Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 22, 2005, 2005 Mr Anthony DeBarros 58 Orr's Ave Hyannis, MA 02601 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 58 Orr's Avenue, Hyannis, MA was inspected on 8/17/05, by David D. Coughanowr , R. S., a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Conditionally passed"under guidelines of 1995 TITLE 5 (310 CMR 15.00) DUE TO THE FOLLOWING: Waste water effluent was observed in the hole above the top of the leaching pit. You have from the date of the system inspection to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALT DEPARTMENT SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Sign e item 4 if Restricted Delivery is desired. Vc��&rtssee ■ Print your name and address on the reverse X so that we can return the card to you. B. Received by(Printed Name) C. D (f elivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No k oN� A Mr Chester Goraski C:, 0-99 N l 5 Drury Lane Stoneham, lVlA 02180 _ 2 f)96erviceType I El Certified-Mail ❑ Express Mail ❑ Registered) ❑ Return Receipt for Merchandise ,EZI'Insured-M it ❑C.O.D. l/SPsj 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service'iabel) �= PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No. G-10 • Sender: Please print your name, address, and ZIP+4 in this box • PUBLIC HEALTH DIVISION TOWN 01 BARNSTABLE 200 MAIN STREET HYANN11, MASSACHUSETTS 021('11 • A o i p Postage $ 3 �s MA o2� Ln Certified Fee CCI Postmark Return Receipt Fee t�EP 5 M (Endorsement Required) / rq r3 Restricted Delivery Fee C3 (Endorsement Required) l7 Total Postage&Fees ,$ / .�\ U$p5 f 1 .-a s 7 r� C6 O Street, t.No.;or PO Box No. nn e"--------------- -------------------------- t e YIP+4 rif o l i o Certified Mail Provides: c A mailing receipt o A unique identifier for your mailpiece o A signature upon delivery o A record of delivery kept by the Posfal Service for two years Important Reminders: n Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE 'IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811?to the article and add applicable postage to cover the fee.Endorse mailpiece 'Return Receipt Requested".To receive a fee waiver for a duplicate return receipt, a USPS postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise.the clerk or mark the mailpiece with the endorsement"Restricted Delivery". e If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for,postmarking. If'a postmark on the.Certified Mail receipt is not needed,detach and affix.label with postage and mail. ' IMPORTANT:save this receipi and pfesent-it whenlmaking an inquiry. PS Form 3800,May 2000(Reverse) 1 02595-99-M-20 87 • • • • • •- • • a _ r..,..CO � Postage $ •,3� _\�cj �!,A O� ul Certified Fee / \� CO n 3o/ Postmark Return Receipt Fee H re m (Endorsement Required) e�� AUG 2 9 f005 a Restricted Delivery Fee 0 (Endorsement Required) O O Total Postage&Fees $ �SPS C� Ateef;4pAko-" Ti ^� or PO Box No. O -- -------------------------------•------------------- C3 C State,Z/P+4 U/ Certified Mail Provides: o A mailing receipt o A unique identifier for your mailpiece . o A signature upon delivery o A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt is required. c For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If'a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry.. PS Form 3800,May 2000(Reverse) 102595-99-M-2087 i Commonwealth of Massachusetts 31 ./g' Title 5 Official Inspection Form `t Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the computer,use 58 Orr's Avenue- Hyannis only the tab key Property Address to move your Anthony DeBarros cursor-do not use the return Owner's Name key. 58 Orr's Avenue Owner's Address VkA Hyannis MA 02601 City/Town State Zip Code Date of Inspection: August 17, 2005Date 2. Inspector: David D. Coughanowr, R.S. Name of Inspector Eco-Tech Environmental Company Name l 43 Triangle Circle Company Address -- Sandwich MA `=' 02563`"' City/Town State Zip Code`, _ 508 364 0894 ' Telephone Number W M 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 16.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation b/�the Local Approving Authority �t � 6 °1 S August 17, 2005 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5-2160.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iG^M yVy Subsurface Sewage Disposal System Form A. Certification (cont.) 58 Orr's Avenue Property Address Hyannis MA 02601 Cityrrown State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection 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. 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: t5-2160.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2of16 E Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 58 Orr's Avenue Property Address Hyannis MA 02601 City/Town State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection 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 E pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ 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 t5-2160.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ,M Sva y`ev Subsurface Sewage Disposal System Form A. Certification (cont.) 58 Orr's Avenue Property Address Hyannis MA 02601 City/Town State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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: i ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 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: t5-2160.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form G'M A. Certification (cont.) 58 Orr's Avenue Property Address Hyannis MA 02601 City/Town State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 'h 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 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 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 less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes No ® 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. t5-2160.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 5of16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 58 Orr's Avenue Property Address Hyannis MA 02601 City/Town State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection El El 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. t5-2160.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form B. Checklist 58'Orr's Avenue Property Address Hyannis MA 02601 City/Town State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection Check if the following have been done. You must indicate "yes" or"no" as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, including the SAS, located on site? ❑ ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] t5-2160.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments iG^M Sve� Subsurface Sewage Disposal System Form C. System Information 58 Orr's Avenue Property Address Hyannis MA 02601 City/Town State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan Number of current residents: 6 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 362 gpd g ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-2160.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 8of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments S9 Subsurface Sewage Disposal stem Form ,M P Y C. System Information (cont.) 58 Orr's Avenue Property Address Hyannis MA 02601 City/Town State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner 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) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 20+years. Certificate of Compliance issued 5/24/85 (Board of Health permit#85-225) Were sewage odors detected when arriving at the site? ❑ Yes ® No 1:5-2160.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form C. System Information (cont.) 58 Orr's Avenue Property Address Hyannis MA 02601 Cityrrown State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): Depth below grade: 1feet 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 ❑ Yes ❑ No certificate) Dimensions: Not determined Sludge depth: Not determined Distance from top of sludge to bottom of outlet tee or baffle Not determined Scum thickness Not determined Distance from top of scum to top of outlet tee or baffle Not determined Distance from bottom of scum to bottom of outlet tee or baffle Not determined How were dimensions determined? Not determined t5-2160.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 58 Orr's Avenue Property Address Hyannis Ma 02601 City/Town State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection 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 was not opened because conclusive evidence of system failure was observed at leaching pit. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to.outlet invert, evidence of leakage, etc.): 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): t5-2160.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ,M Subsurface Sewage Disposal System Form C. System Information (cont.) 58 Orr's Avenue Property Address Hyannis MA 02601 CityFrown State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection 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.): Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Not determined 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.): D-Box was not opened because conclusive evidence of system failure was observed at leaching gallery. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2160.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 58 Orr's Avenue Property Address Hyannis MA 02601 City/Town State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection 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: 1 ❑ leaching chambers number: ❑ 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.): While digging down to leaching pit, the soils became increasingly wet and discolored, and a distinctive septic odor was detected. Effluent was observed standing in hole above the top of the leach pit. t5-2160.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments ;M s Subsurface Sewage Disposal System Form C. System Information (cont.) 58 Orr's Avenue Property Address Hyannis MA 02601 City/Town State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5-2160.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 14 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form P Y 1M Sy0 C. System Information (cont.) 58 Orr's Avenue Property Address Hyannis MA 02601 City/Town State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection 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. LEACH PIT LOCATIONS Oz❑ D-BOX s A B C 1 22 ft 9 ft 2 32 ft 22 Ft 3 36 ft 36 ft SEPTIC TANK 6 A C EXISTING DWELLING # 58 W Z J W W H 3 I 0RR ' S AVENUE NOT TO SCALE Lt5-2160.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form '7M C. System Information (cont.) 58 Orr's Avenue Property Address Hyannis MA 02601 City/Town State Zip Code Anthony DeBarros August 17, 2005 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 15 feet+- Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: USGS topography maps You must describe how you established the high ground water elevation: USGS topography maps indicate property is approximately 15 feet above nearby Aunt Betty's Pond. t5-2160.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 16 of 16 0, 1b W 1Z 1- -VAI- Fimi3 .. . .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD' IF HEALTH ............... �G7V----- OF......-... ppliration for Dispatial Works Tonstrurtion Errant plication is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal yst at: . ............. 7 ---- - ----------- --- . ..............4............................................ L AddrW...1j"'I or Lot ... .... .. .. . ....... . . ...0:2 ......... .... 4. ..... Address....ef& .. ............,Ownea I ..... ... ................. ...... Installer Address Type of Building Size Lot... feet U ms..........I............................ Garbafe Grinder Dwelling—No. of Bedrooms__________ -Expansion Attic aOther—Type of Building_.e,09A..��........ No. of persons____________________________ Showers Cafeteria-1� Other fixtures ..e?,,& Q. . ................................................................................................................................... Design Flow......... ........................gallons per person per day. Total daily flow............... ...............gullons- 1:4 Septic Tank—Liquid capacity/*."_ ...gallons Length dr:�.4.... Width.25F��Av_ Diameter...-!!7-/- A%., Depth...I�-!' ..- Disposal Trench—No_.................... Width_._.__......__.___.. Total Length.......... ... Total leaching area.____________ sq. ft. Seepage Pit No.___!_______________ Diameter........ Depth below inlet......4 .......... Total leaching area419'0!!1_1e1;..sq. ft. Z Other Distribution box Dosi t k 1-4 Performed by. 901) ...... Percolation Test Results ..... -------Lan-ZON..7�.............................. Date .............. Test Pit No. LV....&..minutes per inch Depth of Test Pit____________________ Depth to .......... 44 Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water._____._______._.______. ............ ----- ---------A"'.30 5 V Zz-,q----------------------**-----------**....... -- -------------- 0 ',Description of Soil......... �4 C... ......................................................... .................................................... ------�_1___-_- ....................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ A reement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the o-* ion of'ILPIE 5 of the State Sanitary Code— The undersigned further agrees not to lace the system in ,:o o rat-n til er to of Compliance ee i ed by the b%d of h Ith. ed....... ... . . . ........ ... .. ..................................... ................... Da ication Approved By D4 ..... . .................................... ......!1. .. . Date pplication Disapproved for the following reasons:.............................................................................................................. ......................................................................................................................................................................................................... Date PermitNo......................................................... IssuedL........................................................ Date Z4 No...............tL_ FEic 7....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT 19 ..........................................OF.....:�'­�..J......................... ./ Appliration for Dhiposal, Works Tonstrurtion "pamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: -111 ............................................................ .............. .. ......................... �jlcation-Addr6s -A A........................t:�................................... .... .................. .. ........ ................................................. --- ---------- ------- Owner, -- ...... Owner Addr ess4 ..... ........ ....... �...... ................ Installer 7 ... ss Addre Type of Building .. ......U .. e_. Size Lot..'_.......... .... .......Sq. feet ,_4 Dwelling—No. of Bedrooms____.....................................Expansion Attic Garbage Grinder '4 Other—Type of Building ......... No. of persons____________________________ Showers Cafeteria - Other fixtures ......6 ........................................................................I----------I................ ---i5------------------------------ WW Design Flow________'?. _____gallons per person per day. Total daily flow_____.__.............. gallons -----------*---- i� .0 ................... Septic Tank—Liquid' capacit/_'t !�_.gallons Length6�.-_. Widiji.±............ Diameter-_'^.,_'.. Depth.."-'n...... . Disposal Trench No. ...................: Width-__._ ___. Total Length.........�e....... Total leaching.area--------- Sq f t. Seepage Pit No.--Z.............. Diameter.________........ Depth below inlet_.__.: Total Total lem2ac, area....... ft. Z Other Distribution box Dosing tank 4 '_4 $4 Percolation Test Results.! Perfo rmed by.1_.,Z._'___ t ............................................... Dat,.'....................................... 4 Test Pit No. ... __._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........................ .............. .............................. -----------i---------------4............................ ........... .....7, 4 l 1, 7...... ........'5 0 Description of Soil........ - 4e. 11 �)0 / Z i ...... ................. ........... ---------------- �' �9------------------------------------------------------ U .............................................. ............... .1 ........ ............................................................................................................................... W �4 ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable.___________ ................................................................................. ............................ ....................:...... ----------------------------------- ---------I--------------------------------------------......................... Agreement: The undersigned agrees to install the aforedescribed Individual. Sewage Disposal System in accordance with th provisions of TITIE 5 of the State Sanitary Code— The undersi ned further agrees not, the system in o er t' til a✓Cer to of Compliance has,.,been-i§Sbed by the blNmdof health. C"77 . Ile ..................... ....... ......... ............ . . ............................. ........ ..... 77 a� /2A cation Approved By ... . ...... ........... - - /!"............ - Y Date pplication Disa provedfoi,the following reasonv............................................................................ ..........-.-.-.-.- ......................................................................................................................................................................................................... Date PermitNo................................---------------........... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I - ,Ale _#v ;7�-z .... ................. OF.........4 ...................................................................... Tp�rrfif iratp of Tomphaurr THL§ 1S1T0,CEFRT1kY, Thatt%,Jndividual Sewage.Disposal System constructed or Repaired by....... ...... ...............................;�........................7.................................................................................................................... at...................................................... ------------------*------------------------------------ ---------------------I------------­------------------I—-------------- has been installed in accordance with-Vie provisions of TIJ�kj of The State Sanitary'Code as d9scribed in the application for Disposal Works Construction.Permit No...................?.?5, ........ dated_----- ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST ED AS A 64ARANTEE THAT THE SYSTEM WILL FUNCTION ........... . SATISFAC RY. .. ........ ... .... ... DATE......................S;.......Z.4....._... .............. Inspector................ ..... ......THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH V ................................OF._..---- ..................................................................... No............. FEE:....................... Disposal Varks T-50ustration "Pamit Permissionis hereby granted....... ..................................................................................................................... to Construct or\Repair an i,�ndvidual Sewage Disposal System • at No-1-i2t........ ...... ............................................................................................ -------------- ...I---------...--------.... Street Z35 as shown on the application for Disposal Works Construction Permit 0..[_­= .......... ------.................................. j,rrAt, 0 ................... ----------------------------------------------------------------------- DATE......... ...... ....................................... Board of Health FORM 1255 A. M. 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S rid' PQ�✓�rE �w sum .LEGEND EXISTING SPOT ELEVATION 010 CERTIFIED PLOT PLAN EXISTING CONTOUR - 0 - - Rtws"EO SPOT ELEVATION [� 711410'NEID CONTOUR 0 Lo-7- i3+lulc&-.,n,NE0)oarZ's ACE NrA�..,s NOTE' The 'location of any, existing under_�ound 'sewerage, IN wells., or. other utilities shown ont} is. plan is approx- imate only as determined ,from records and/or verbal information. The contractor is responsible' forthe verification of the existing locations in the field. S.CALEr l" - 44-0.' DATE ' rao 22"PiR5, iCDREDGE ENGINEERING Ca IN BAa�sTRv Cl1ENT..1s��i._ I CERTIFY THAT . THE PROPOSED EOISTERE ZRL ISTERIR JOB NO 8____O/3- BUILDING SHOWN ON THIS PLAN CIVIL" AND CONFORMS TO THE ZONING -LAWS E G lj R OR.BY�..r. Dp OF BARNSTABLE , MASS 3EPw ' t 712 ,MAIN STREET CH: 8Y, (u : 2Z .S�" HYANN I S, MASS. SHEEtJ- OF �2- DA E REG. LAND SURVEYOR Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection • One winter Street,Boston,Ma. 02108 •Tole Gil pi t D.E.P. Title V Septic Inspector P.U. Box 2119 Teaticket, MA 02536 WILLIAM RWELD (508 564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FOR p�CQc� w PART A /r l CERTIFICATION „y OCTorrl,� Aveaive. 2 0 1997 Property Address: 586 p.? d.Hyannis Lot 13+14 Address of Owner: TOWN OF Date of Inspection: 10/16/97 (If different) Hrgt y�Epjq@(E Name of Inspector: John Oraci Wilshire Credit Corp I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Ci Company Name,Address and Telephone Number: 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 sewage disposal systems. The system: X Passes This Inspection Is based on criteria defined In Title V Conditional) Passes code 310 CMR 16303.My findings are of how the system is y performing atthe time of the Inspection.My inspection does _ Needs F rth Evaluation By the Local Approving Authority not Impyany warranty or guarantee of the longevity ofthe F81Is septic system and any of Its components ussfUl life. Inspector's Signature: Date: 10116197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing'this inspections. 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] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: i One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,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,unless the owner or operator has provided the system inspector with a copy of a Certificate of CoThpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exliltlation,or lank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised M7)97) One Winter Street . Boston,Massachusetts 02108 is FAX(617)556-1049 • Telephone(617)292.5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION (continued) Property Address: 580rrs Rd.Hyannis Lot 13+14 Owner: Nfilshire Credit Corp Date of Inspection:10116197 — Sewage backup or.breakout,or. high.static water level observed.in.the distribution box is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced . obstruction is removed distribution box is leveled,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] 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: — The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. — The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. 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. Yes No — Backup of sewage in 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 cesspool. — SAS is in hydraulic failure. (revleed 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 580rrs Rd.Hyannis Lot 13+14 Owner: Wilshire Credit Corp Date of Inspection:10116197 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers 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 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. 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. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following:criteria apply to large systems in addition to the criteria: 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: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. I (revised 04127197) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 58 Orrs Rd.Hyannis Lot 13+14 Owner: Wilshire Credit Corp Date of Inspection:10116197 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x — As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. __ — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site. x The 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. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, If different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C.is at issue, approximation of distance is unacceptable)]15.302(3)(b)] pevlaed 0Q1111, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 59 orrs Rd.Hyannis lot 13+14 Owner: Wllshire Credit Corp Date of Inspection:10116197 . FLOW CONDITIONS RESIDENTIAL: Design flow: 339 g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy:4 months ago COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:a gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: rda Last date of occupancy: nla OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped to the last year. System pumped as part of inspection: (yes or no)No If yes,volume pumped:U gallons Reason for pumping: nla TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy !7 Shared system(yes or no) ( if yes,attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date Installed(if known)and source Information: 19f16 Sewage odors detected when arriving at the site: (yes or no) No (rsvlaed 04l27)97) !r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5E orrs Rd.Hyannis Lot 13+14 Owner: WiilshireCredit Corp Date of Inspection:10115197 SEPTIC TANK:X (locate on site plan) Depth below grade: 15" Material of construction:x concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: t.e•5^H5.7"w4.10^ Sludge depth:5" Distance from top of sludge to bottom of outlet tee or baffle: 22" Scum thickness:7" Distance from top of scum to top of outlet tee or baffle:V Distance form bottom of scum to bottom of outlet tee or baffle:5" How dimensions were determined: Measured Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound.Recommend pumping system now and then maintalned every year. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle:rda Date of last pumpingn't- Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level.in relation to outlet invert, structural integrity, evidence of leakage, etc.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: 2• Material of construction:_cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line?o- Diametec 4" Q,imments: (conditions of joints,venting,evidence of leakage,etc.) (revised 04127ST) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 58 Orrs Rd.Hyannis Lot 13+14 Owner: Wilshire Credit Corp Date of Inspection:10/16197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nra Capacity: nla gallons Design flow: rva gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) rVa PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) n!a (revlaed 0427197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 58 orrs Rd.Hyannis lot 13+14 Owner: Wilshire Credit Corp Date of Inspection:10116197 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required. but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type. leaching pits,number: 1,0t10 gallon Octagon leach pit leaching chambers;number:rda leaching galleries,number: n1a leaching trenches, number,length: n1a leaching fields,number,dimensions:n1a overflow cesspool,number:n1a Alternate system: rda Name of Technology._n1a Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The leach pit Is structuraffy sound and functioning properly.It was empty at the time of the Inspection,shows signs of being 314 full. CESSPOOLS: (locate on site plan) Number and configuration: nla Depth-top of liquid to inlet invert: n1a Depth of solids layer: nla Depth of scum.layer: n1a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) n1a Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) .n1a PRIVY: "(locate on site plan) Materials of construction: n1a Dimensions: n1e Depth of solids: rda Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) nra (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 56 Orrs Rd.Hyannis Lot 13+14 Wilshire Credit Corp 10/16197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n � 0 C a f3 n Page ! of 10 (revived 04r2719� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 59 Orrs Rd.Hyannis Lot 13+14 Wilshire Credit Corp 10116/97 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts r (reylsed0427197) page 10 at. 10 TOWN OF BARNSTABLE LOCATION 158 ®r r� true- SEWAGE# n$ A�ILLAGE ASSESSOR'S MAP&PARCEL r� NAME&PHONE NO. M IC 0_0 n vl xx l/) SEPTIC TANK CAPACITY C)00 LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER (\1 a1. I20^T PERMIT 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 Leach'n Facility(If any wetlands exist within 300 feet of leach' oo facility) Feet FURNISHED BY _ l ti s Via._ 25a 3n 25 24 4'9 - f / / Water- Service ervice Orr's Ave TOWN OF BARNSTABLE D '0—OCATION SEWAGE # VE.LAGE , ASSOR'S MAP Ty `j INSTALLER' NAME&PHONE NO. j SEPTIC TANK CAPACITY Imb ice. LEACHING FACILrrY: (type) �/g�I � T/ (size) + NO..OF BEDROOMS ' BUILDER OR OWNER PERMTTDATE: CDIMPLIANCE DATE: Separation Distance Between the: dK V,044-i4Y, Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Q � 3 V. ! AA q�aq IJz� A3= TOWN OF BARNSTABLE LOCATION,51 D r r S J4 VC 4 u e.. SEWAGE # �J LLAGE 4,11 s ASSESSOR'S MAP & LOT / /9 INSTALLER'S NAME&PHONE NO 6 �h dt SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) \`* �5. NO. OF.BEDROOMS �61��I1 BUILDER OR OWNER PERMITDATE: \ LIANCE DATE: Separation Distance Between they Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by § ! • \ � \ y§VI |I / � | ! I �� . . . . . . . . . . . . , L 0•C A T ION SEWAGE PERMIT NO. /3 Z 7,S� VILLAGE I N S T A L ER'S NAME ` ADDRES • D • S UI-LDE 01 OR OWNER DATE PERMIT ISSUED _ S2 DAT E COMPLIANCE ISSUED ' J r � � _` f M� " � i i 1 ,� y U" �� �� O J *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C_ VENT PIPE (0 Least 24 inches tall SECTION A -A ALL OUTUT PIPES FROM THE *PAW 144NAM: ys 10' min. from Schedule 40 PVC w/Charcoal Odor'Fllt;� DISTRWTION BOX SHALL BE Existing Foundation -house to septic on'tonic PROFILE VIEW OF ADDITION TO LEACHING SYSTEM SET LEVEL FOR AT LEAST 2 F7. CONCRETE COVER D-BOX cover must be -0 Septic tank covers nvat be ro I I - , 6 in. of finished grade 21 3 - 5'OUTLET KNOCKOUTS 1 1 2' Grade ovet Septic Tanli 99,00 ,­Groda over D-Box 99.50 3/4" to 1 1/2 ' Washed Crushed Stone 1/' `� -A TOP OF FOUNDATION ELEV. 100.00 (Assumed) withiln 6 in. of finlishied grade SAS 99.50 3" of 1/8" - 1/2' Washed Peostone- IT 1&5' 94LET -OUTLET 4- PVC (CAPPED)INSPECTION PORT TO BE S 0.02 3 HOLE H-10 INSTALLED AND TO BE WTHIN 6* OF GRADE ;C"am An T. BOX 3' Maxinwm cover Top OF System- Ehrv. -96.14 P;er.��_A 2 0 12' EXIST. S-0.01 Greater XIST. PIPE In 1,000 GAL. S- 0.01. A 4* SCH. 40 Tee�/ 416 CNI 30' Per foal 0- Effective Depth FROM EXIST. FOMI ATM an SEPTIC TANK F) co PLAN SECTION CROSS-SECTION 3 H 11 Box \4- 7 P., laii, AT:,/ ch.wED. CY) 5' in 5 UrAts @ 625' 30' CONCRETE FULL I". > H-10 0.83' (10 inches) N LO ch > Cn 0 3' 7C) 3'L_31.25'--� 3 HOLE H-10 DISTRIBUTION BOX > in 6 in.of 3/4--1 1 ISOM SYSTEM PROFILE > 41) 0) NOT TO SCALE compacted starve > 0 -6 If A cr) -27 25�-- Soo It 0 11 Effective Length Not to Scale 3.5'- 3'� >. O1 �3.5' 0 SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES 8 In.of 3/4"-1 1/2* 0 4) compacted starve < Effectt" VIdth 0 INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN 0 1. Contractor is responsible for Digsafe notification, Verification of Utilities 0D NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE -1 0 (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes. Z Bottom of Test Hole 1 Elov.-88.00 NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECT1VE HEIGHT IS 10" 2. The septic tank and distribution box shall be set Groundwater Observed NOW OBSERVED level on 6" of 3/4"-1 112" stone. 3. Backfill should be clean Sand or gravel with no stones over 3" in size. 4. This system is subject to inspection during installation PERCOLATION TEST by Carmen E_ Shay -- Environmental Services, Inc. 5. The contractor shall install this system in accordance with Title V of the Massachusetts state code, the approved plan Date of Percolation Test: SEPTEEMBER 7, 2005 and Local Regulations. Test Performed By. CARMEN E. SHAY, R.S-, C.S.E. 6. If, during installation the contractor encounters any Results Witnessed By: WAIVER (Per Barnstable B.O.H.) soil conditions or site conditions that are different EXCAVATOR: Shay Env. Svcs. from those shown on the soil log or in our design Percolation Rate: Less Than 2 MPI 0 42" installation must halt & immediate notification be mode to Carmen E. Shay - Environmental Services, Inc. Test Hole Test Hole 7, No vehicle or heavy machinery shall drive over the No. 1 -- No. 2 NIF RUTH H. SHUMAN septic system unless noted as H-20 septic components. DEPTH SOILS ELEV. ELEV 8. Install I'Llf-I-ite gas baffles or equals on all outlet tee ends. ___0_ _ 99.00 0 99.50 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Sandy Loom Sandy Loom Cbb 10. All solid piping, tees & fittings shall be 4" diameter 10 YR 3/2 10 YR 3/2 Schedule 40 NSF PVC pipes with water tight joints. 0"-9' A, 98.25 0*-6" -_ A, 99.00 150.44 11. Municipal Water is Connected to ALL OF The Residence and Abutting Sandy Sandy Properties Within 150 Feet. Loom Loom 10 YR 5/6 10 YR 5A THE PROPERTY LINES ARE APPROXIMATE AND 9"- 40' Be 95,67 6"- 42'1 Be 96.00 LOTS # 13 & # 14 COMPILED FROM THE SURVEY PLAN GENERATED BY Medium/Coarse Medium/Coarse 31' ELDRIDGE ENGINEERING OF YARMOUTH, MA Sand Sand 22,710 Square Feet ENTITLED "CERTIFIED PLOT PLAN OF LOTS 13 & 14 ORR'S AVENUE, 25 HYANNIS, MA" DATED FEBRUARY 22, 1985 2,5 Y 7/4 _ Y 7/4 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN 40"- 132' C, 30"- 132' C, 88-,Ia IT SHOULD BE USED FOR NO PURPOSE OTHER THAN ---37.25' ------ THE SEPTIC SYSTEM INSTALLATION. A.11 4 PVC • EXISTING TO BE PUMPED OUT D-Boxobi PROJECT BENCH MARK Vent TEST HOLE #1 TOP OF FOUNDATION k.0 ELEV. 99.00 NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE ELEV. 100.00 (Assumed Nz_t %'�4 . V_ r FROM THE EXISTING TO BE DISPOSED D-Bo. If 0 TEST HOLE #2 OF AS PER BOARD OF HEALTH SPECIFICATIONS. ELEV.= 99.50 - LOT #12 F7D LOT # 15 THERE ARE NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY Perc #1 Depth to Perc: 42' to 60" C11) 34' ASSESSORS MAP 291 PARCEL 199 Perc Rate= 2 MPI k6 ----�Q ----- - -f Groundwater Not Observed EXIST- 1000 GAL.j Failed LEGEND No Observed ESHWT SEPTIC TANK I ADJUSTED H2O Elev. = None L_ _J Leach Pit [104X 11 DENOTES PROPOSED SPOT GRADE 2-18* DIAM_ ACCESS MANHOLES EXISTING X 104.46 DENOTES SPOT GRADE EXISTING EXIST. .A 3 BEDROOM Deck PL PROPERTY LINE HOUSE 96 PROPOSED CONTOUR IWIT OU11JT #58 EXISTING CONTOUR r THE ACCESS COVERS FOR THE SEPTIC TANK, ......... DISTRIBUTION BOX AND LEACHING COMPONENT I I SET DEEPER THAN 6 INCHES BELOW FINISHED 7,7 GRADE SHALL BE RAISED TO WITHIN 6" OF DEEP. TEST HOLE & STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. PLAN VIEW INSTALL TUF-TITE GAS BAFFLES OR EQUALS i PERCOLATION TEST LOCATION 3--24' REMOVABLE COVERS 6 FOOT STOCKADE FENCE LJ L mkv clearance a" 2- In Wet to outletOUTLET -11 &LET'T' F Llipu4d level A J 10'rube P LOT PL A INt_E I N s -r - - I ^Ew-1- f 5, _r I C 1 min. Gee NeM. Liquitl dept h ; ,9 OF PROPOSED SEPTIC SYSTEM UPGRADE_ PREPARED FOR 150.00, 1 I 1 MR . ANTHONY DEBARROWS CROSS SECTION END-SECTION I i i �T --------------------- ------------------------ ------- # 58 OR S AVENUE TYPICAL 1000 GALLON SEPTIC TANK NOT TO SCALE "961 HYANNIS , MA Design Calculations 0 A VJ�, _/V OF PREPARED BY: 0 ASS Number of Bedrooms: 3 Equivalent to 330 Gal./Day (330 Gal./Day Min. per Title V) (40 FOOT RIGHT OF WAY) Garbage Grinder: No M CARNEY E. SHA Y Leaching Capacity Proposed: 330 Gol./Day Minimum (Min. Per Title V) ENVIRONMENTAL SERVICES, INC. Septic Tank : - 2 x 330 Gal./Day = 660 USE EXIST. 1,000 GAL. Septic Tank. S U) SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch 0. 1 P.O. BOX 627 Bottom Area: 0.74 gal/sq. ft. x 372.5 sq. ft. = 275.65 gallons 0 20 40 50 EAST FALMOUTH, MA 02536 Sidewall Area: 0.74 gal./sq. ft. x 78.72 sq. ft. = 58.25 gallonscf Providing: = 333.90 gallons NITAF \ ' TEL/FAX : 508-539-7966 Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS. HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, 1 "=20' DRAWN BY: CES DATE: SEPT. 8, 2005 TO BE USED NTH 3.5' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE SCALE: 1"=20' PROJECT#SD797 FILENAME: SD797PP.DWG SHEET 1 OF 1 ON THE ENDS. NO STONE UNDER.