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Home My WebLink About0129 SUNNY-WOOD DRIVE - Health ---1 9 SUNNYWOOD , HYANNIS A = 272 228 a i o o o i e 0 0 0 ` I Commonwealth of Massachusetts a�a o202.� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Sunnywood Drive `a Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 co page. City/Town State Zip Code Date of Inspection 11.) 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. `�px��H OF tM 1ii�� Important:When filling out forms A. Inspector Informationon the comuter, use only he tab James JAMES ym James D.Sears key to move your Name of Inspector cursor do not return use the return Jim The Inspector Man ��"•.�' �,.�� key. Company Name �� •., G \``�� CI P.O.Box y�igrr�s INSP1E`\`S1 —I Company Address West Yarmouth MA 02673 City/Town State Zip Code rB7� 508-364-4398 S 1623 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 8-6-19 ;sptor'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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 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: I The system is a 1000 Gal. Tank D Box and four chamber's 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form .� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 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): i I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety.or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sew i p age Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -u- 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 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 j 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: 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts - p Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 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 AampaA is less than 6" below invert or available volume is less than 1/2 day flow A FAC/{/NG ® 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 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 J ❑ ❑ 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 t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts 1p Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is Hyannis required for every y MA 02601 8-5-19 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 and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? I ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts : ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Sunnywood Drive L Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 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): 330 Description: 1000 Gal Tank D Box and Four Chamber's. 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 El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: I Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5lnsp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 r Commonwealth of Massachusetts p Title 5 Official Inspection Form JJ10 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �u 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 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 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No I If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No I Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as.part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.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 io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Sunnywood Drive • V Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 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: D Box and Leaching 2000 permit#2000 - 275 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 28"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.): Pipeing is 4" PVC SCH 40& SCH -20. 151nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Rio Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wv, 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 page. City/Town State Zip Code 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 ❑ 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: 1000 Gal. Precast H-10 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank and outlet cover at 18" below grade w/inlet cover at 5". In and out let barrle's. No sign of leakage or over loading 151nsp.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 i 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete '❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: I 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 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 i 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x 16"-28" below grade w/one line out. Box is clean and solid. No sign over loading or solid carry over. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form -Io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 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: 4 ❑ 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 i Commonwealth of Massachusetts ' Title 5 Official Inspection Form <� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 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.): Leaching is four infiltrators. Leaching is 30" below grade. Camera out and probe area. Leaching is clean and dry w/No sign of overloading. 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 I Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t i t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 118 Commonwealth of Massachusetts Title 5 Official Inspection Form Yle Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 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.): I 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 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 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 Q o 0 2 ��'2 = ' c2 y-C A 3X I 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 �o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .V 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N� 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: I You must describe how you established the high ground water elevation: Auger T.H. 10' no G.W.. Bottom of chambers at T below grade. Bottom of chamber's at 7'above T.H. Depth. 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 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,!% 129 Sunnywood Drive Property Address Priscilla Wallace Owner Owner's Name information is required for every Hyannis MA 02601 8-5-19 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 3,,13 b �� No G.w l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE LGC ATION , � a tru a c[ioa/l _ SEWAGE # .I.AGE T 'i*,,�9SESSOR'S MAP& LOTZ72_ gW INSTALLER'S NAME&PHONE NO. /I11 h C.�/).a_ S'�.r� / C SEPTIC TANK CAPACITY /sd0 _ LEACHING FACILITY: (type)y tl1'52 T/Z4 7o eS (size) // k-2 3 NO.OF BEDROOMS I OR OWNER PERMIT DATE: I'— �'"�>C�'IJ COMPLIANCE DATE: .�7 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 leac ' g facility),�� Feet Furnished by 61. n Lu � � f . � .r� No. '�yQGq Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: er PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pp[ication for 33igpooar *pgtem Conotruction Permit Application for a Permit to Construct( . )Repair( )Upgrade(' Abandon( ) O Complete System Mhdividual Components Location Address or Lot No. 1 aj`�i ti/ Owner's Name,Address and Tel.No. � I �11V Assessor's Map/Parcel , Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �+%0-c,*11ksrov'' C- Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow '3C� gallons per day. Calculated daily flow �3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank N000 Type of S.A.S. L Description of Soil A&ca Cr)Y WJW— r ��Nature of Repairs or Alterations(Answer when applicable) - _ � 4 't G,L-i d ,y2� (I S`c�-P. o,tiStnra�f —�- (�t�C/oc,��-�.'- r l 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 Enviro ental Code and not to place the system in operation until a Certifi- cate of Compliance h issue y t s Signed A Date I Application Approved Date L�_� �� Application Disapproved for the following reasons Permit No. Date Issued it Y No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yet PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE; MASSACHUSETTS_., Zipplication for Miopomi *p5tem Construction Permit 3 Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) El Complete System &6dividual Components Location Address or Lot No:,' �� ,ti� �� Owner's Name,Address and Tel.No. Assessor's Map/Parcel �"� ✓v S Z r YV G�1 3-aa Installlleer's Name,Address,and el.No. Designer's Name,Address and Tel.No. 0—c,`P�1�.Srot (- Type of Building: Dwelling No.of Bedrooms �✓' Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 73 gallons. Plan Date Number of sheets Revision Date Title S, Size of Septic Tank � S--t " k' \000 Type of S.A.S. <-- ` Description of Soil V W VKe, ; - Nature of Repairs or Alterations(Answer when ap licable �rN�' h `` — �L t�k �vQ [.� �` S-r'we_ ow-S6Icef —4- �t� va �- Date last inspected: Agreement: ,,�' / r•- 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 Enviio mental Cod_and- of to place the system'in peration'un°til a Certifi- cate of Compliance ha&bgen issued by this o . - tr` - Signed - `� . r"Date Application Approved Date 4$r-- � s Application Disapproved for the following reasons. Permit No, - Date Issued ------------------------------,, —---.—--------- THE.COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( =)Repaired ( )Upgraded(V ) Abandoned( )by ,r 11 D—co V S at 10� V NN W U.00 N N S has been constructed in accordance with the provisions of Title 5 and the for Disposal Syistem Construction Permit N O�V— Installer Designer The issuanpe-of-thisr)eerrmit shall-not be construed ai,a guarantee that the sy will function as esigne� Date Inspect--------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpooal *pOein Construction Permit Permission is hereby granted to Construct( Repair( )Upgrade( `Abandon( ) System located at zLC-\ 1" lVCMD 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:Constructi�ust-�mp within xhree,years of the date of {- Date: APProd. 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERNIIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated L dy concerning the property located at 1 t,LK2=�b meets all of the following criteria: �/• The 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. There are no wetlands within 100 feet of the proposed septic system (./ There are no private wells within 150 feet of the proposed septic system 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 not be located less than five feet above the ma.dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation ' _the NMA_`{. High G.W. Adjustment7l�_o DTFERENCE BETWEEN A and B J� SIGNED : DATE: �79710 [Sketch proposed plan of system on back rl�" q:heahh folder.cert 2 TOWN OF BARNSTABLE -- -_--_-.--.___.-- I LOCATION / a _So rr ccidan SEWAGE #; � VILLAGE 055SOR'S MAP & LOT�?I;_ INSTALLER'S NAME&PHONE N0. ih_ _,�, X70?; SEPTIC..TANK CAPACITY /soo LEACHING FACILITY: (type)5LA/1-2 _X Q 7o•�S (size) /l .Y.2 3 NO.OF BEDROOMS PERMITDATE: DATE: .,? Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 leac g facility)��— Feet Furnished by'- 6 Z' i 4i 1 r� 12-0 A5SESSOR S MAP NO'Z- -3 PARCELZ-��' e6y el ` L_9CAT�lp* EWACE PERMIT NO. Ao V'I L L 71V,01� E Hs CcAt A?t**-S - • NINSTAJLLE 'S NAME� & ADDRESS 'y ��7 ALL Yt a� 8 U I L D E R OR OWNER ►^ C`p '�� OA T E P ERMIT ISSU D DATE COMPLIANCE ISSUED 2t i S ''�4 �� - • �� I� r, i �� `i ;� � �. b� .. . . � �� a,3 - a THE COMMONWEALTH OF.MASSACHUSETTS Y BOAR® OF HEALTH ..........'Il�H1N.......................OF........BARM.TABIZ.......------------.-•--............--•---.............. ApplirFation for Diipaaii al Marks Tnnitrnr#iun ramit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: ................_........_...................................................................... ...................... ........................................................... Location-Address or Lot No. .........gi m.Realty---r tost------------------------------------ .....................BUMy..I9k1od. �........................ Ow L e Hya r Address nnis...................................... ............... Installer Address U Type of Building Size Lot.........19!981....Sq. feet Dwelling—No. of Bedrooms....................3.......__...___.._._.Expansion Attic ( ) Garbage Grinder 'k Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures .................................. 'f W Design Flow...............55........................gallons per person per day. Total daily flow..................330.....................gallons. WSeptic Tank—Liquid capacitylOO_Q..gallons Length._ 1.-G"... Width..A 1 10"-Diameter---------------- Depth5.174.11...... x Disposal Trench—No..................... Width-................... Total Length.....................Total leaching area....................sq. ft. 3 Seepage Pit No.....I............. Diameter.._....121....... Depth below Total leaching area...251.......sq. ft. Z Other Distribution box ( x) Dosing tank ( ) a Percolation Test Results Performed by.-Cape..C.od.-SurveY__COnsu1tants....... Date..._•.: Test Pit No. 1.....2.........minutes per inch Depth of Test Pit----12�_........ Depth to ground wa OF f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground STEPHEN 'tG Description of Soil---Q-G ..Y 9d--LQ --- -3..-- Br... Sandy v_ a ._ ...: ... -- bi .----------•---------•-------- x �_..stratifie _ -144" stratified ---•-••-•-•-•-•-----•-•----•-•.................•----•••-...... sd .....-"--•------•----------------•----•--•--•-•--•----••--- . A DIo.S30O2P 1I8 y U Nature of Repairs'or Alterations—Answer when applicable.................................................................... s�f/pp� ETA --------------------------------------------------------------------------------------•.............-------------------------------------------------------------------•••-- Agreement: The undersigned agrees to ins 11 the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE; 5 of the ate S itary Code— The undersigned further agrees not to place the system in operation until a Certitcate C n has een issued by the board of h J igned...........�- -. • ........ ................................ Date Application Approved By......... -•-- ..... --•••- ...........�-.."_ Date Application Disapproved for t e following reasons:................................................................................... .................. -•-------•-----------•---------------------------------------------•--------------------•-••-•------------••--•-•----•-----......----•-----•--•-----------•---••--••-••-•--•-----•••---•--•--••......••- •Date PermitNo......................................................... Issued....................................................... Date � I No..... Fss... ......(�v THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --•--..... .....................O F.........BARNSTA$LE..... r ApV iratinn for Dispnsttl Works Tonstrurtinn Prrutit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: ................................................................................................. ....................... .......................................................... tMrn Location t-�1Address �,.M�, T�or,�Lot No. .......... ...Lir,.L74.................................. ........................)3=y-_lRJll�d.. .................................... ►Wa Own / H Address ------------ k..r v-..I................................. •---------------•-....---yax.rus ---------...-----------•------•--.......... Installer Address Type of Building Size Lot...........19!.981...Sq. feet ., Dwelling—No. of Bedrooms...................... ................... Attic ( ) Garbage Grinder (M j WOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------------------•-----------------------••-•-•---•--..........•••••• W Design Flow................rt`5.......................gallons per person per day. Total daily flow.................... ......................... WSeptic Tank—Liquid capacity..1QQQgallons Length...8�."V. Width.__'..-10'biameter---------------- Depth 5--,,,4" x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.................. sq. ft. 12 3.57 251. Seepage Pit No..................... Diameter________________ Depth below inlet_._...._._.___.. Total leaching area... Z Other Distribution box ( Dosing tank Percolation Test Results Performed by.._! . -.;U; Y.-�12�u tt-'.`.__.... Date..... ��-•-- ' OF Test Pit No. 1.......___2______minutes per inch Depth of Test Pit...... Depth to ground wate ��qJ'M MAgc 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wa G O Description of Soil....7VII Vbod p,=- V-30n Brn. Sandy Subsoil; o Ab�YP� rnl w ..._MULSQIY.. 30"-84"1...stratified..sand--an....g 4 a4"�144" Sl'.Sc'3t3. i.e xr A No.30216�� y sand•------------••--------•-•------•----•-•-----•------- •--•-----••---•-----• •-•-•-. --•-...----•--•--•---•---••---•---••--•-•-•-------•--•--• ��, ��srE�'v�� U Nature of Repairs or Alterations—Answer when applicable....__.................................................................... . sSfOEa --------------•-------------------------------------------------------------...---..._...-- --- Agreement: G u� The undersigned agrees to inst�ll the aforedescribed Individual Sewage Disposal System in accordance with ir the provisions of TI'I IIE 5 of he State S. itary Code— The undersigned further agrees not to place the system in operation until a Certificate of�Complian has been issued by the board of healt . igned................... . ..... ....... ....... ................................ Date Application Approved By.......... `- g-•------- Date Application Disapproved for t ollowing reasons:.............................................................................................................. ---------•-••.....--•-••.............•••--•-----------•--•••------•---•-••....----------•--•-••••--------...----•--------•-----•-------••-•--•---•---••••-•••-----•-----••---•--•-•--••••-------•..._.._. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS ff BOARD OF HEALTH C" .....OF......... ..... .. . .. .... ..................................... Trrtif iratr of f�nntp1mi na THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by-••------•-----••--------------------------------;-------------_.-.-----.-.-...-.-.-.---•------------------------------•----..------.--.-.---------------------...-.---------..-------------•------- r,� Insta has been installed in accordance w1 I provisions of T = of The State Sanitary Code a i desc e in the �. /___Z application for Disposal Works Construction Permit No.7 _.__ ../_...... dated......... s-----)_- -.--.- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI TI N SATISFACTORY. DATE........... :...._.. --�-�......................•----------••-•-- In Spector...t :._._.. THE COMMONWEALTH OF MASSACHUSETTS '�'` BOARD OF HEAL,�T(H No.... - .............. 1......U.. OF.............. NS%. .......................... � Disposal arks %fnr inn rrntit Permission is hereby granted--•••--• ..l�'L...... -• ............ ------------------------------•-----------•---•--------------- to Construct6 ) or Re air ( ) an Individu Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit No. :: Dated----=/'j. ........ i lBoard of Health DATE....../2_----a l-,11. ................................. FORM 1255 HOBBS & WARREN. INC.. 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SH GRADE 2„�Q _._.. r I $: .° STONE-;� - M&F/LLB 12 M/N. ,e� M .f �+"✓f'` I - 3 CL EAR 3 EAk - --- - --- -- _ A' -,elf! -A' - - I - - - OUTLET S Win-i - -- _-,_ _ _ -- -- __} _ _ _ -----_ �,_— - ----- - �. •;r � TL T PIPE -- - -...-. - -- 0 ' i t - *10 � /C- ; ,� _ E� 6 M/N ,� MfN.- fi'MfN �i t � AS REOU/RED OA E L DEPTH O TEST - I - -- -- _ RA TE' _. -- T IO"M/N DIST ---- -- - _ _ _._. --- -- r r � y �,•� ---. _- _----- _--- ---- --.---- --- - -----4--- � $ LE EE - - - ,' Ot/TLET TEE � e{ <� - I / I uu fJ. - (� I F TC 7 �- 4 C.1. GAL. r OUTL ET TEE DEPTy: I I 1NLE, AND OUTLET 4* 0"` MINIMUM (. I PT/C TANK I PRECAST OR BLOG�1' MIN IL _ , i I ; •f; °� L_---- TEES TO BE c"4ST L'OUID DEPTH J4` AT LiOU/D DEPTH OF 4" I �I `' ) !9"" „ ,5" -- -�6 - C N.STR E �� SEEPAGE P/T i Q'`1y� OF TEST, IRON, SCHED 4O `, I•'i 2q' 6 ��. i CDNCRE T Tl^ 1D I l 3 -- - — I _ PVC. OR CAS, /'IV ,. . O L� q, , 1, i iJr >}C?I Pl-ACE GONCRE TE ':', 25 �, - ' - MIN. '� Fi�61TE CONC.RETF �..,- 34 g' BOTTOM ON LEVEL STA8LE,9,4SF -� coNsrR ti. Vk, :� warERTIVHr1. - I I ST q g•�, i gR %NL E T TEE PROVIDED v/DE D WHERE SLOPE FOUNDA77ON ' • - - TANK %G 8EABLE TO WITHSTA:V:_ OF INLET PIPE EXCEEDS O.OB % OR ' t i 8OTTOM OF TANK ON LEVEL 5T4,t?LE 845E /N 4 PUMPED SYSTEM 20`M/N l H-/O 10.4 D/NG UNL ESS UNDER I 1.�- - --- ------ ----- - — + 1�2'WASHED STONE I # r A f I I ¢ PAVEMENT OR/N DRIVE.H-20 LOADING UNDER P4VFMENTOR y i DRI vE.xr ►s_._ - .• NOTES I _F. ' LA VI 1. TN/., r'LA�J /S FOR THE DL:S1,s,ti A.NC �.,ON,� /,RG t. Tf ON (?, THE SEWAGE c7lSPOS`AL FACILITY ONLY. .5C A LE 1 INV. AT BUILDING .} ' 2 A L L CONSTRUCTION METHODS AND MA TERIAL 5 ,5UAL" L_ CONFORM TO IN AT SEPTIC TANK(/N) ' h1A,5`�`. D.E.G E T/TL E ,4 ,V O THE_ t:: '` ~. x� BO.ARO OF- � INV. AT SEPTIC TANK((.YlT1 HEALTH REGULATIONS_ fi 70 ,� r :� `is I INV, AT DIST BOX(INI I i /NV AT DIST BOX(OUT) ; 1 _ 3 AT LEACHING FACILITY h.3 _ -- _ ' BOSTON, MASS. WORCESTER, MASS- 1 !' AT BOTTOM OFPIT: 91sU e HAL,IFAX, MASS. NORWELL, MASS BEDFORD, MASS. LE.XINGTON, MASS, HYANNIS, MASS. MANSFIELD, MASS. t'I�ANSTC+N, R.d. aERRY, N H E3 C 1 3 , i S s I _ _ _DESIGN DATA : ,4EQU/REL?. SEPTIC TANK CAPE C SURVEY SEPTIC TANK PROVIDED _1.4.E 0�_GAL. `� x RE U/R LEACHING IN FACILITY '�i T`` � f .,,s (n .� �• � . , ,, , '� + , I ,� � „ .,.•• /...) ED SIZE LE C G • f 1, "�'.. Street Route 6A • . '+ Barnstable Village. Massachusetts 02630 � Number. (617) 362-6133 7-P ; �} i DIVISION OF '71k: k v BOSTON SURVEY CONSULTANTS INC a ,SIZE OF LEACHING FAC IL I T Y PRO VIDED ENGINEERING • SURVEYING • PLANNING j �+c TYPE OF SYSTEM TITLE: I > I c a :. i 2,57'y DESIGN S I/N Ids �° VV 0 ice%��++ A rA,' t _ _ ,-� - � y� a� (per'd �� ` d��+"� i.. f n�f•�,% P�,a'�t c� .r.,� �y ® ' a 1+'� ,.� VI :. F 0 R,AF, C .�1 c oh-1v REAL Tr ;WIV57 -' ' s vY .•' +PS £,✓,. T P fir �w. f n' FA{�1',f 4. C . � '' ,. f.'•/:'i,v y_,+^4..L- !',,J`,,�,..�,( _�._ 5,144 r"� 4? SCALE AS SHOWN '' METERS .°, S LZ cp"4 f✓.5 FEET 0 10 Zo 1 ' 39 DATE: ZJ E c' 2 0, t 7''3 4 .� / v`' / COMP:/DESIGN: R t4 Aof ,� A vv CHECK: R PM / C t / � w DRAWN- 1Y vv 7- Jo FIELD. AD AF 67 6 / .:� " >E T -�' .4 !�, '' C'/•ter�iv� ,•�rR r"ors!'. - -- ---- -_ E 3 1 ra f4h mna! /to � �+ �' = / SS f"V T F�c.�.✓✓lf' �>.�.r r�i�rr�" FILE NO: r"v 51'ce ox- DWG. NO: JOB NO: 03 - 14 4 AP awe t� � � 3, t�..��'.� •J' of /s'%'"�` r�� SHEET: ._I OF: ._._._._._ . .._------- -'°----__ . ...... , •.::..,......w,..«.,e:.w+.....,,,. ......: _-,,...,-..:w..,.. .•.a ,,.,....,. .-.,.,_.K.....s..a...m:..,,.«.w.....,..,.•..-:,.+. .. ,...+.ewe..,,. .. •.. ..,.•,.z :. .....,..•-...,...,.x...R:.....•- ,,•,,,,s,..•t.....«..FF..�.,. ...., ,.T...,,.. ., -