HomeMy WebLinkAbout0418 PITCHER'S WAY - Health (3) 418 Pitcher's Way
Hyannis
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
418 Pitchers Way
Property Address
Eva& Patrick Golarz
Owner Owner's Name
information is
required for every
Hyannis Ma 02601 2/12/2020
page. City town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Imngoutf rms A. Inspector Information vi (�f'39a
filling out forms
on the computer,:.
use only the tab
Sean M. Jones
key to move your Name of Inspector
cursor-do not
S.M.Jones Title V Septic Inspection
use the return Company Name
key.
74 Beldan Lane
Company Address
.Centerville Ma 02632
Cityrrown State Zip Code
774-248-4850 smjonestitle5@gmail.com, S14522
sean@�mjonestitl65.com License Number
@ 1
B. Certification
I certify that: I am.a DEP approved system inspector in full compliance with.Section 15.340 of Titles
(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 disposalsystems. After conducting this inspection I have determined
that the system:
1. Passes
_. p q _.
p. 2. ❑: Conditionally Passes
3.: ❑ Needs Further.Evaluation by the Local Approving Authority
4. ❑::Fails
7
2/1.2/2020 . :.
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of.Health or DEP)within 30 days of completing this inspection. if the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the.appropriate
regional office of the DEP. The original 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.
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 1 of 18
f
Commonwealth.of Massachusetts
P . Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form - Not for Vol untaryAssessments
418 Pitchers Way
Property Address
Eva& Patrick Golarz
Owner Owner's Name
information is required for every Hyannis Ma 0.2601 2/12/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 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:
s.
:The property located at 418 Pitchers Way Hyannis is served by a Title V septic system consisting of a
1500 gallon septic tank, distribution box and 9 Hi Cap Infiltrators.: The system was found to be in
proper working:condition at the time:of inspection.
2) System Conditionally Passes:
_.
One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
.the Board of Health, will pass.
Check the box for."yes","no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound,.exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic.tank will pass inspection if it is structurally.sound, not leaking and. if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El Y ❑ N ❑ ND (Explain below):
s.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth.of Massachusetts
UTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
418 Pitchers Way.
Property.Address
Eva & Patrick Golarz:
Owner Owner's Name
information is
required for every Hyannis Ma 02601 2/12/2020
page. Cityrrown State Zip Code Date of inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
El 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): .
El 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 El El ND (Explain below):
El 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):
El broken pipe(s) are replaced ❑ Y ❑ N. ❑ ND:(Explain below):
El obstruction is removed ❑ Y:: :❑ N El ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
:Conditions exist which require further evaluation by the Board of Health in order to:determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
418 Pitchers Way:
Property:Address
Eva& Patrick Golarz
Owner Owner's Name: .
information is required for every Hyannis Ma 02601 2/12/2020
page. Clty[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:
_..
El 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.
El 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 m, provided that no other failure criteria are triggered. A co of the analysis must
pP P 99 copy Y
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:
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
V� 418 Pitchers Way:
Property Address
Eva & Patrick Golarz
Owner Owner's Name
information is required for every Hyannis - Ma 02601 2/12/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary. (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes. No
El ®; 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 '/day flow
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number:of times pumped:
❑ N Any portion of the SAS, cesspool or privy is below high groundwater elevation.
Any portion of cesspool or privy is within 100 feet of a surface water,supply or
❑ ® tributary.to a surface water,supply.
El ® 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,
❑ E 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 d
❑ ® Y p 9 Y... 9. _.. 9p
10;000 gpd.
I]:::
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 p.
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 11 of a public water supply well
t5insp.doc-rev..7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,
Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments
418 Pitchers Way Property Address
Eva & Patrick Golarz.
Owner Owner's Name
information is required for every y
H annis Ma 02601 2/12/2020
page. 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 andexamined? (If they were not
0 El
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 systs?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev..7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for.Vol untary.Assessments
418 Pitchers Way
Property Address
Eva& Patrick GolarZ
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/12/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): _ 5 . _ Number of bedrooms (actual): . 5
DESIGN flow:based_on 310 CMR 15.20.3 (for example: 110 gpd x#of bedrooms):
550 gpd
Description:
4
Number of current residents:
i
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑. Yes [E No
If yes; discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report:) El Yes ®: No
Laundry:system inspected? ❑ Yes. ® No :.
Seasonal use ❑ Yes ® :No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
q.
Sump pump? ❑ Yes ® No
Current
Last date of'occupancy:
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface.Sewage Disposal System Form -Not for.Voluntary Assessments
418 Pitchers Way.
Property Address
Eva& Patrick Golarz
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/12/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont:)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310.CM 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
p.
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holdin tank
9 present? ❑ Yes El No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes El No
Water meter readings, if available:
Last date of occupancy/user Date
Other(describe below): s.
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection?
p 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
Title 5 Official Inspection Form
Subsurface Sewage:Disposal System Form -Not for.Voluntary.Assessments
418 Pitchers Way
Property Address
Eva& Patrick Golarz
Owner Owner's Name
information is
required for every Hyannis Ma 02601 2/12/2020
page. City/Town State . Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
Septic tank, distribution box, soil absorption system
ElSingle 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
El Tight tank. Attach a copy of the DEP approval.
Other(describe):.
Approximate age of all components, date installed (if known)and source of information:
system installed 2/23/2004 per town records
Were sewage odors detected when arriving at the site?:. ❑ Yes:.® No: : .
5. Building Sewer(locate on site plan): : -
2
Depth belowgrade
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.):
Joints in good condition, no:leakage, vented through roof.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
418 Pitchers Way
Property Address
Eva& Patrick Golarz
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/12/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
- 1.5 .
Depth below grade: feet
Material of construction;
®.concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed bya Certificate of Compliance?.(attach a copy of certificate) El Yes ❑ No
. 1500 gallons
imensions:..
5"�
Sludge depth: _.
Distance from top of sludge to bottom of outlet tee or baffle
3'
2', .
Scum thickness
. 711
Distance from:top of scum to top of outlet tee or baffle ::
Distance from bottom of scum to bottom of outlet tee or baffle
1011
How were dimensions determined? Opened covers and took
..
measurements
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 does not need to be cleaned now but should be done soon and again:every 2 years for proper
maintenance.water level was even with outlet, tank was not leaking and was structurally:sound.
t5insp.doc•rev..7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface.Sewage Disposal:System Form -Not for Voluntary. Assessments
418 Pitchers Way
Property Address
Eva & Patrick Golarz
Owner Owner's Name
information is
required for every
Hyannis Ma 02601 2/12/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap.(locate on site plan):
Depth below grade: feet
Material of construction;
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum.thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural.integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade'
Material of construction:
❑ concrete -
❑ metal El fiberglass El polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
.Design Flow: gallons per day
t5insp.doc•rev.7/2 612 0 1 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 11 of 18
Commonwealth.&Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
418 Pitchers Way
Property Address
Eva& Patrick Golarz
Owner Owner's Name
information is
required for every Hyannis Ma 02601 2/12/2020
page. Cltyrrown 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. El No
9. . Distribution Box:(if present must be opened) (locate on site plan):
011
Depth of liquid level above outlet invert
Comments (note,if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage.into or out of box, etc.):
Distribution box was video inspected and found level and in good condition with no rota Water level
was even with outlet invert with no signs of past backup.
I,
i
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c� Commonwealth of Massachusetts
i
Title 5 Official Inspection Form
Subsurface.Sewage Disposal:System Form - Not for Voluntary Assessments
418 Pitchers Way:
Property Address
Eva& Patrick Golarz
Owner Owner's Name
information is
required for every
Hyannis Ma 02601 2/12/2020
page. Cltylrown 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:
9 HI Cap.
Infiltrators
El leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev..7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.13 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface.Sewage Disposal System Form Not for Voluntary Assessments
418 Pitchers Way:
Property.Address
Eva& Patrick Golarz
Owner Owner's Name
information is Hyannis Ma -02601 2/12/2020
required for every y
page. Cityrrown 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.):
Leaching facility was video inspected from vent and was found dry with no.signs of past hydraulic
overloading.
i
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 El Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of pond ing;.condition of vegetation,
etc.):
t5insp.doc•rev..7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 14 of 18
I
Commonwealth of Massachusetts
d Title 5 Official Inspection Form
Subsurface Sewage Disposal:System Form -Not for Voluntary Assessments
418 Pitchers Way
Property Address
Eva& Patrick Golarz
Owner Owner's Name
information is
required for every Hyannis Ma 02601 2/12/2020
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.):
q.
p.
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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
418 Pitchers Way
Property Address
Eva& Patrick Golarz
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/12/2020
page. Cityrrown 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
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P 0 L
�I 2-r
(fit 1? 3
AZ 23 f' I
A-3 s' b
133 Gy
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
r
Commonwealth of Massachusetts
-
- Title 5 Official Inspection Form
r Subsurface:Sewage Disposal:System Form - Not for Voluntary Assessments
418 Pitchers Way
Property Address
Eva & Patrick Golart
Owner Owner's Name: .
information is
required for every
Hyannis Ma 02601 2/12/2020
page. City/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 12+
d
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),:,.
El Checked with local Board.of Health-explain:
❑ Checked with local excavators, installers-(attach documentation) ..,
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater was established by accessing town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 18
Commonwealth of Massachusetts
- - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
418 Pitchers Way
Property Address
Eva& Patrick Golarz
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/12/2020
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
I �
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
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i TOWN OF BARNSTABLE
LOCATION SEWAGE # ,20d y— 062
VILLAGE ASSESSOR'S )VLtP SLOT 2� '01��d I
INSTALLER'S NAME&PHONE N0; ����
SEPTIC TANK CAPACITY"
LEACHING FACILITY: (type)' y 4 OM W129Cam—(size)
NO.OF BEDROOMS 11 `
BUII..DER OR OWNER
U�
PERMTTDATE: COMPLIANCE DATE: "ZT0
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any we exist Feet
within 300 feet of leaching facility)
Furnished by
l3
1
TOWN OF BARNSTABLE
LOCATION SEWAGE # .20d 062-
VILLAGE ASSESSOR'S M ILOT.2q I-DI f d o I
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Q ' '?�-(size)a`2gq 9144 1�"/)a
NO.OF BEDROOMS
BUILDER OR OWNER A'aaf
PERMPTDATE: 1.1 COMPLIANCE DATE: a a 0
Separation Distance Between the:.
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
(a-
W
J
No. �/ll� , •� FEE
COMM®NWFALT14 OF MASSAC14USETTS
t Board of Health, daS�i�;�1Rtai.E MA.
}
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairXUpgrade( ) Abandon( ) -XComplete System ❑Individual Components
Location Owner's Name
Map/Parcel# Address
Lot# Telephone#
Installer's Name Designer's Name
Address NNC� Address - j (;, _ a
Telephone# Telephone#
Type of Building � `�1�(�� Lot Size a eR q SO sq.ft.
Dwelling-No.of Bedrooms �t Garbage grinder (4
Other-Type of Building No.of persons Showers (y)%Cafeteria (t)/
Other Fixtures
Design Flow (min.required) gpd Calculated design flow r?>C Design flow provided gpd
Plan: Date ale I 1' 4 Number of sheets Revision Date
Title to C:�LARA.
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS cc-, .
The undersigned agrees to install th ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees Q no to plpfe the tem' ration Certificate of Co pliance has been issued by the Board of Health.
Signed Date O
Inspections
�>• `ATV"r>•�.;�.:.: «. ,::;w,,;,,.ci;.-..�ti;.:�..�;.1;-+.Es«=-�:+»�.-• .�t..e�,��,. - �,:"r'--.ww�:�s.� �r�. �",`'i''�ti""�s�."y '.�"Xr'�=t-�"`�-�r
L• •tp. X P' Y SF
No. FEECOMMONWEALTH Of MASS3�CHUSETTS
Board of Health, k AfkQ e*T_A 9L MA.
APPLICATION FOP DISPOSAL S l STE,ACONSTRUCTION PERMIT
i
Application for a Permit to Construct( ) Repai�(�F)`Upgrade( ) Abandon( - wc-mple a System ❑Individual Components
Location ,4 }�/ ,C 5 WC" . HVtC f)r_,1 g Owner's Name jC
Map/Parcel# Q AddressAi �
Lot# Telephone#
Installer's Name' `�� Designer's Name t`9f`i14lZtG
Address Address M
Telephone# Sde-,944 aRCC Telephone# �"� .-C)
Type of Building Lot Size �3cA `l J sq.ft.
Dwelling-No.of Bedrooms t\ E'12_�t J Garbage grinder (44-
Other-Type of Building t�Af1X"1� �+ No.of persons Q Showers (Y)�Cafeteria (i.)/ '
Other Fixtures �Y',. �ctyCL�. ►' �irQr 1l(11� r ,,�-Y� tiak-'
Design Flow(min.r4equired) gpd Calculated design flow ) .3L3 Design flow provided 551 •6 gpd
Plan: Date �114R1 h -Number of sheets ! _ Revision Date .•,
Title
Description of Soil(s) `
Soil Evaluator Form No. Name of Soil Evaluator Mql Date of Evaluation C�
rt"
(^
DESCRIPTION OF REPAIRS OR ALTERATIONS
J
The undersigned agrees to install the bovbed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the/item operation until-a Certificate of Compliance has been issued by the Board of Health.
Signed f / �"�� Date Z 1-Ile
Inspections
:..:��,;�-..max-�.� ..�<�:� ;.�-._.;� ���:y.�-..�.,.;:w�.�9_,..„::�.<-,.-�e.�. ,•--- -Y- - p=- - r -
No. U�! ` G� FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, re MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( )
by:at 9 r 0, " "I"kw,L
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ?ij 0 ll -00, dated 1 f�! y Approved Desig�>a Flow (gpd) /
Installer 1 f
Designer: Inspector: ! ' � f ,. JL Date:
�. r
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. COMMONWEALTH
` �/� �T}��T ( T FEE r ) � t
SETTS
Board of Health, e-ml A9 MA.
DISPOSAL SYSTEM CONSTRUCTION
PERMIT
Permission is hereby granted to; Construct( ) Repair( _Upgrade ) Abandon( ) an individual sewage disposal system
at /-// P{ kee-s L4 o. ,., N\)a, "-vt1 Sj as described in the application for
Disposal System Construction Permit No. �' ` dated ` e�- lo.q
-�
Provided: Construction shall be completed*within three years of the date-of-this per<mt. A111ocal conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Dated / d04 Board of Health
T'owwof Bairnstable
�pF tHE 1p�
y�P ti� Regulatory Services
Thomas F. Geiler, Director
+ BARNSTABLE,
63. �0� Public Health Division
rEo �A Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:.508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: 0 tf
Designer: Z5�A4 Installer: "
Address: Address:
a� 5 _
On oZ ` ` was issued a permit to install a
(date) (ins a ler)
septic system at F,4cksS W$�c , o�ngc based on a design drawn by
(address .
Ci2 ram- dated
,:;2 IR 0
(designer)
YV\/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 as-built by designer to follow.
(Installer's Signature)
CA MEN G,
o a
is c a
(Designer's Signature) (Af i esigner's Stamp He No. 81
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CER
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM N�1iSe�P "
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVI 1
THANK YOU.
Q:Health/Septic/Designer Certification Form
3-24"DIAM. ACCESS MANHOLES
z
i SECTION A -A
r
VENT PIPE O Least 24 rcoal tall
( -'r.
NOTE. ALL PIPES ARE TO BE 4 SCHEDULE 40 P.V.C. ) V ;" L C G SYSTEM ;'�/ :" '; ... : tt' £ , ''�:: '':Niter+,+�l5w�''�'r��_,,,:�-.-a:.;-••'�'`--
10' min.,from Seh•dule 4d PVC w/Charcoal Odor filterPROFILE IEIY OF ADDITION TO EA HIN NOT TO SCALE ITO,se to septic tank , /
Existing Foundation r to ?
Septic tank coven must be 3 of 1 8 1 2 Washed Peastone
T.O.F. aev. = 100.00 {
1 within 5 In, of finished grade over SAS- 9&50 a / / .,I ; I ,
Grade over Septic Tank - 9&50 Grade over D-Box - 98.50 /4` to 1 1/2 ` Washed Crushed Stone /-� -.
INLET T +¢ �/ �4
.- - moson : INLET '.'. .-. �."� '+
S 0.0 Top toed - Elev. -95.40 ppt THE ACCESS COVERS FOR THE SEPTIC TANK,
2 A tIST. x Top of SAS - Elev. -94.90 I` DISTRIBUTION BOX AND LEACHING COMPONENT
Y9
(M-20) DST. BOX y`� T SHALL BE RAISED TO WITHIN 6" OF -> � °10 5=0.01 or -
GrsotK
EXIST, PIPE N NEW 1,500 GAL t A 0" Effective Depth -' " ' ""T' 'T" *' FINISHED GRADE !i t' y-.="-� _
FROM FOUNDATION R SEPTIC:TANK
w co STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITE GAS BAFFLES OR EQUALS
'�� H-10 O 20' 9 Unit ! 6,25' 56.25' b :.,
n co o ON ALL OUTLET TEE ENDS +uw s
�P coNCRETE FULL FouNOATro ° N ,f rn w 0.83' (10 inches) .25' 3,25' PLAN VIEW j'
✓/ Q�( p y u ! LL:��6.25' 3-24• REMOVABLE COVERS a 1�
( � SYSTEM PROFILE m 2.50'
mrao+r.rvs�'+i��,m, +�se7tfkd'o�ar�eta 1`r.4cc�e+�[o�s�
c m v �-2
Effactiv
7 Not to Scale - 11 a Length ti
• 4' 4'
'� 4•
y .5'I 3 min. in, inlet
- GENERAL NOTES
c c 0 '1 i INLET 8' mM �min, Inlet to outlet a. Mir0 SOIL ABSORPTION SYSTEM (SAS) I .i - _e OUTLET
6 k.of 3/4'-t t/z' ,r 1. Contractor is responsible for Digsafe notification
/O �Q Effective Vldth _to'rnx I 7 .
l�l compacted stone $ -INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN 5' -r * f§ L_ " 5•-r and protection of all underground utilities and pipes.
Bottom of Test Hole t Elev.-M.50 •: E r
v (OR EQUIVALENT) Not to Scale g Liquid min. 2. The septic tank and distri t{tion box shall be set
♦Obs. Groundwater - Test Hole-1 Elev.= NONE OBSERVED i b °i'"" LI0"b °'pU' level on 6 of 3/4 -1 1�2 -stone.
/ .' 3. Backfill should be clean sand or gravel with no
NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10" 5 -a stones over 3" in size.
I ^'' "'`'''� •' " '"' ;" ;' ' 4. This system is subject to inspection' during installation
to'-o'
by Carmen E. Shay - Environmental Services, anc.
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE CROSS SECTION END-SECTION 5. The contractor shall install this system in accordance
with Title V of the. Massachusetts state code, the approved plan
and Local Regulations,
\ \ FOUNDATION o' SEPTIC TANK ►-45' D-BOX *--20'-BLEACHING FACILITY TYPICAL 1500 GALLON SEPTIC `TANK
6. if, during installation the contractor encounters any
(H- 10 LOADING) soil conditions or site conditions that are different
from those shown on the soil !log or in our design
installation must halt & immediate notification be
made to Carmen E. Shay Environmental Services, Inc,
�,-
9 ?. No vehicle, or; heavy machinery shall drive over the
septic system unless noted as H-20 septic components.
Install Tuf-Tite gas baffles or equals on all outlet tee ends.
\` \ \ \`� 9, All Distribution Lines shall be 4" diameter Sch. 40 NSF PVC pipes.
i
�a 10. All solid piping, tees & fittings shall be 4" diameter`
PERCOLATION TEST Schedule 40 NSF PVC pipes with water tight-joints.
11. MUNICIPAL WATER NOT AVAILABLE AT SITE and Surrounding Properties
Date of Percolation Test: FEBRUARY 17, 2004 EXISTING WELLS WITHIN 150 FEET OF SAS AS SHOWN ON PLAN.
Test Performed By. CARMEN E. SHAY, R.S., C.S.E.
\ F \ `� �� { Results Witnessed By. WAIVER per BARNSTABLE BOH
Excavator. Roberts Septic Service
Percolation Rate: Less Than 5 min./inch ® 63" BELOW GRADE.
_ NOTE"
LOT 1 -^ Test Hole THE COMPILEDPROPERTY
LINES
N E AREA PROXIMATE AND
TED BY
\ / # r PLAN.\ �\ / �/ r l No. 1 CAPE & ISLANDS ENGINEERING, INC of MASHPEE, MA, DATED 9/10/02
_I .1 ENTITLED PLAN OF LAND LOCATED IN HYANIS, MA ,
DEPTH SOILS ELEV. "
0 98.501 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
Sandy Loam IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
/ 10 YR 3/2 THE SEPTIC SYSTEM INSTALLATION.
\ 0•-8" AP 97.67
mow\\ Sandy Loa
7.5 YR 5/6 THERE AREA NO WETLANDS LOCATED WITHIN A 200' RADIUS OF THE SAS.
81- 18' Be 97.00
Mod
Sand
7.5 YR 7/6 NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
18"-144" 0, 86.501 FROM THE EXISTING SEPTIC SYSTEM TO BE DISPOSED
OF AS PER BOARD OF HEALTH SPECIFICATIONS. °
a' 1
\ r EXISTING SAS TO BE PUMPED DRY &
REMOVED TO FACILITATE INSTALATION OF NEW SAS
r 11 1
i
� , I ASSESS R .MAP -, 29i CEL -0 S - PAR 018/001
� + Perc #1` ZONING - RESIDENTIAL'
`� \��L�9GF` t\ 0�• i LOT l#z Depth to Perc: 24" to 42
_ - o
'Perc Rate � min Inch
28 950 S are Feet + - Groundwater' r
qu Not Observed
THERE AREA NO WETLANDS LOCATED WITHIN A 200 RADIUS OF THE SAS.
' cP BOTTOM. OF;TEST HOLE Elev. 144' •
ADJUSTED H2O Elev. = No Adjustment Required.
I
I
ALL OUTLET PIPES FROM THE
1 _
. ••••� DISTRIBUTION X SHALL BE
LEGEND
\� \ BOX 12' CONCRETE COVER S
` SET LEVEL FOR AT(EAST 2 FT.
AV
DRIVEWAY / ` � PROJECT BENCH MARK °NocKou01rs „ 2
` +I / - ,: 8X0 DENOTES PROPOSED
G,4$ �\ a - �� TOP OF FOUNDATION taa• Iz" INLET SPOT „GRADE
\ , INf- r \ ELEV. = 100.00 (Assumed) OUTLET
( \ ••v`� ` a' e DENOTES EXISTING
wy
\ 'ti a 2 X r, 104.46 SPOT GRADE
It I
PLAN-SECTION GROSS SECTION PL
PROPERTY
0 ERTY LINE
6 HOLE H-20 DISTRIBUTION BOX y� PROPOSED CONTOUR
i W� NOT TO SCALE - - - -
1 / 4' 97- 97 EXISTING CONTOUR
Y.�\ \\ f� EXISTING er ® DEEP TEST HOLE &
-' ;- S BEDROOM a'. PERCOLATION TEST LOCATION
9 --- - - -----' ` �\ HOUSE Design Calculations
418 Number of Bedrooms: 3 Equivalent to 330 Gal. Da 6/�, q J y (330 Gal./Day Min. per Title V) ,
Garbage Grinder: No FENCE
9
Leaching Capacity Proposed: 550 Gal./Day Minimum (OVERSIZED AT OWNERS REQUEST)
1500 al.
Septic Tank - 3 x 550 Gal: Da = 1100 USE 1 500 GAL Septic Tank.
P / Y P
. PRIVATE DRINKING WATER WELL
O
i g k �
E
O Septic Tan SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch
DECK Bottom Area: 0.74 gal/sq. ft. x 625 sq. ft. = 462.50 gallons
th -\ Sidewall Area: 0.74 gal./sq, ft. x 120.35 sq. ft. - 89.59 1lgollons REVISIONS
:,Failed Providing: = 551.56 gallons
Cesspool Use: NO. DATE: DEFINITION
\ (9) INFILTRATOR HIGH CAPACITY H-10 UNITS, HAVING A' 0.83' (1O INCHES) EFFECTIVE DEPTH,
TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.25' OF WASHED STONE
`� .atb ON THE ENDS, NO STONE UNDER.
. � I
TEST HOLE #1
ELEV.= 98.50
��O ::, • tt O-Box
'o \ PROPOSED
o, \
•
3.
•ri �, '. � PREPARED FOR :
SUBSURFACE SEWAGE DISPOSAL SYSTEM
4" PVC B 1
'.' '•a Vent Pipe � I
LOT #3 \`�\ ��" 4, i: • OF
M • •0 KIP 8c CARMEN DIGGS a
I
#418 PITCHERS . -WAY
#418 PITCHERS WAY HYANNIS, MA
y
�\ PREPARED BY:
Design NOTES HYAN N I S , MA 02601
Site is in a Zone of Contribution. Permit is requested for Assessed Bedroom House. 1
�� C) , CHaFMAS G CARNEY E. SHAY
System is Oversized for Five (5) Bedrooms at Owners Request ' 1\\ ,�- 6.�1 �� oo C E ENVIRONMENTAL SERVICE'S, ' INC.
_ �_ / t9� ,QN P.O. BOX 627 .
. 11
------------ �a
Fc►sTER EAST, FALMOWTH,; MA 02536
�\ j SANITAR\I`
TEL/FAX,1 : 508•--548-0796
L11-
.. .7
er - CES DATE.E.- E8SCALE 1 =20 DRAWNBY. ,.18, 2004
525 FIL ENA E: SD5 5PDWG 1PROJ CT SD F 1
Q
,