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HomeMy WebLinkAbout0056 CHRISTMAS WAY - Health _56 Christmas Way, �,y, > M1 4 rr- A= 127-022 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is Marstons Mills est Barnstable MA 02668 August 14 2017 required for every g � w page. City/Town State Zip Code Date of Inspection i� 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 filling out forms A. General Information (� on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr use the return Name of Inspector key. Eco-Tech Rapid Response LCompany Name 155 George Ryder Road South Y Company Address Chatham MA 02633-1621 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes tHOFgt4 ❑ Conditionally Passes ❑ Fails EDAVID �Qti El Needs ° er luatio the Local Approving Authority Q4 UGHANO y o.13 p August 14, 2017 Inspector's Signa M iNgpE Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and.copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc°rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �v rdA Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is Marstons Mills/West Barnstable MA 02668 August 14, 2017 required for every 9 page. Cityrrown 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: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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. 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 20t.years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and A.nnellen S. Zalis Owner Owner's Name information is Marstons Mills/West Barnstable MA 02668 August 14, 2017 required for every g page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not 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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4.156 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is Marstons Mills/West Barnstable MA 02668 August 14 2017 required for every 9 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or-less than 5 ppm, provided that;no othe(failure criteriSare triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: Y pp Y You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is, Marstons Mills/West Barnstable MA 02668 August 14 2017 required for every 9 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate.nitrogen is equal.to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ N 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is Marstons Mills/West Barnstable MA 02668 August 14, 2017 required for every g 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? Z ❑ 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)] 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 gpd t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. anc Annellen S. Zalis Owner Owner's Name information is Marstons Mills/West Barnstable MA 02668 August 14 2017 required for every 9 page. Cityrrown State Zip Code Date of Inspection . D. System information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use?^ 1 El Yes ® No Water meter readings, if available last 2 ears usage d 382 gpd 9 ( Y 9 (gpd)): Detail: 2015: 101,000 gallons 2016: 178,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercia`I/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: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is Marstons Mills/West Barnstable MA 02668 August 14 2017 required for every g page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner Was system pumped as-part of,the-inspection? y, 5 ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy - ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is required for every Marstons Mills/West Barnstable MA 02668 August 14, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 32+ years. Certificate of Compliance for a new system was issued 6/18/1985 and an additional pit was added 7/30/1996 (Permits#84-1101 and 96-350 at Health Department). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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,'6tc.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 0.5 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' x 5' x 6'-1000 gallon Sludge depth: 8 inches t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is Marstons Mills/West Barnstable MA 02668 August 14 2017 required for every 9 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 26 inches Scum thickness _ 6 inches Distance from top of scum to top of outlet tee or baffle 8 inches Distance from bottom of scum to bottom of outlet tee or baffle 10 inches How were dimensions determined? design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is recommended at this time. Maintenance pumping is recommended every 2-4 years thereafter with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is Marstons MillsMdest Barnstable MA 02668 August 14, 2017 required for every 9 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑'fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons j Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last cumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is Marstons MillsMest Barnstable MA 02668 August 14 2017 required for every 9 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at 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.): No adverse conditions observed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is Marstons Mills/West Barnstable MA 02668 August 14, 2017 required for every 9 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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, em.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Old pit was empty and dry. New pit contained 1.5 feet of effluent. 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 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is Marstons Mills/West Barnstable MA 02668 August 14 2017 required for every 9 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is Marstons Mills/West Barnstable MA 02668 August 14, 2017 required for every 9 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately L.0 CA NS -OF SEPTIC COMPONENTS -DISTANCES IN DECIMAL FEET -FROM CENTER OF TREE I IN F® T A e ��P�l� �A i 2�®'.TEMI�.M� 1 33.5 37 �C 2 32 31 3 32 21 4- 19 17 5 45 9 THIS SKETCH IS BEST VIEWED IN ��00� COLOR FORMAT G C� LEACH o�Q�� N BOX PIT I�2 �3J DISjpIBUtIO 5 EMS T'#NG DWELUNIG ��F -1 NOT 24 in O TO B OAK SCALE n LEACH o n 4 PIT o m 20 in '� Z MAPLE m A y CW ITS§S TIIVII/r"l1 V WA A ll � 1995 � o RES? 508 364-0894 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is Marstons Mills/West Barnstable MA 02668 August 14 2017 required for every 9 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 11.5 Estimated depth to high ground water: feet r, 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: 12/21/84 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 ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 4 feet above the adjusted seasonal high groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 56 Christmas Way Assessor's Map: 127 Parcel: 22 Property Address Lawrence A. and Annellen S. Zalis Owner Owner's Name information is Marstons MillsAl�'est Barnstable MA 02668 August 14 2017 required for every g page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch cf Sewage Disposal System either drawn on page 15 or attached in separate file GEOHYDROLOGICAL PROFILE -NOT TO SCALE 2 a i PRECAST ZO LEACH W PIT , .;,) BOTTOM OF a LEACHING F PER DESIGN PLAN LEACHING IS- ABOVE HIGH ' GROUNDWATER O v ADJUSTED GROUNDWATER ELEVATION l5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 � I i el Q 47, ono \ j0 l`? o ( \ O ,\ T O r O �"��--• \ �* LLB o ` O 10 \o .� C L o+ 49 --Q-DISTANCE AS CERTIFIED SITE PLAN LOCUS: wOoDSIDE. ? . F- CH2ISTMAS WAY WESt BAgNSTABLa , MASS. REF: LOT So dowiI cwI pe engri/s eef ty PREPAREDFOR: CNRp-4-ES DuG4-�ESf�EY CIVIL ENGINEER'S --_______ � p�v7- -7M\-\..;aC- Sr-- LAND SURVEYORS On MainREG.LAND SURVEYOR �t } 10A SCALE I - 40 �OI DATE 84 1 ' FtECCArION - SEWAGE -SEPTIC TALK - - "D"BOX - - LEACH P� TOP OF FON/ WASHEDSTONE - W I IN- I OUT• IN- OUT• 1 I000 _ IN.G tt SEPTIC ELEV. ELEV TANK . ELEV. ELEV. o ' ELEV. ELEV. - ' ,� . OFVh`•-llh" WASHEDSTONE — TEST HOLE LOG C)Q10 i TEST BY A-oJALA • p.e. C . DEG' ,ESaJE`( TEST DATE _ /T 4 '� WITNESS 'BEDROOM HOUSE DESIGN T.H. +~ 1 T.H. 2 �p—3iC ELEV. ELEV. / 11'�•O !za j 1�4.0 NO I__ J/ PERC RATE _MIN/IN. % DISPOSER DISPOSER 24_ 1 \ \•O 2q, - o FLOW RATE 33QGAL./DAY) ( 3c= SEPTIC TANK 330 04= Ltve�c ICyemn _ gyf' ( I REQ'D SEPTIC TANK SIZE � 1 v•1 O M, LEACH FACILITY SIDE WALL I a�T S�= t1'S t(?_.a) = ZeZ G/D. BOTTOM 2-2 G/D. j TO,TA L • i ,� i i I .ns USE:144 LEACHING ' �r—L_—L" '\o�.o 0 14�--�.___-- �oz..o �Z�C�P•�•. t7,�.M . x � `���. t-�i;.c.-•tr • N WATER ENCOUNTERED • NOTES: (UNLESS OTHERWISE NOTED) L. DATUM(MSL)*TAKEN FROM-__KY(3�??�i-S •QUADRANGLE MAP 2.MUNICIPAL WATER AVAILABLE 3.PIPE PITCH: 114"PER FOOT 4..DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO 44 5.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. nc`�tE ' 6.PIPE JOINTS SHALL BE MADE WATER TIGHT T+ t f 'l=•+'ALA 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. tat :•Yr'(i («f}' I STATE ENVIRONMENTAL CODE TITLE 5 1,jn ^yJ7<}Z r Saw.••253 zoo►¢ c3 w,` - = 1s!^, A r 17 /i /ADS u bT = l .(� ''r'T 5 m M. (�G �7r� �•�+�� �TV��IONAL ENGINEER BOARD OF HEALTH CONTOURS (EXISTING)------------- R>`'NSTt}gtE AMA $(PROPOSED)-O�-O-O- APPROVED DATE r• CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANSI n ereb certify that the application for disposal works 7-7 Y fY pP construction permit signed by me dated- -�� , concerning the property located at �5 ? �' s�S—,,,� ��� meets all of the following criteria: t • There are no wetlands within 300 feet of the proposed septic system • Their are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. i SIGNED: DATE: . LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. i U V,J PT l O THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH `�' .W.h... ............ C�a�nS-�-ab1 `Y OF.......... .. ......... .. ......•--- Appliratiun for Disposal Works Tonu#rwiun Itrrmi# Application is hereby made for a Permit to Construct X or Repair ( ) an Individual Sewage Disposal a I pa 0.��1cNly% ©� So S s at ......_. �.. a -- -------------------- --•y ----...--••---•--•-••--•._.._..---......._--=•:•----••-.......------••-•.----•......_.........._.. Location-Address or Lot No. ................—...._..».....................................-----•-••..._.._........._...-- ..... a Owner /7` ._... ddress .._._..... !ti �- . -•-••-• --- .-••- ........................ .....••----_... •--- Instal er Address Type of Building Size Lot71Uil A......Sq. feet ..� Dwelling—No. of Bedrooms___..__._�J................................Expansion Attic ( j Garbage Grinder ( ) NOther—Type of Building ____________________________ No. of persons..__._....__.._...._..-_...-_ Showers ( ) — Cafeteria ( ) QOther fixtures -------•---...--•-•-----•.........................•--•-----•-••-----.._...---••---------•---•----....... W Design Flow.............5�J.---....--_-•-........gallons per person�grj day. Total daily Pow--•___-__�-�.®_____........_.._..41on� W Septic Tank—Liquid capacity o gallons Length._._.__.._;- Total daily Diameter________________ Depth..___ ..e. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.................sq. ft. Z Other Distribution box (' Do sin tank ( Percolation Test Results 2 Performed by...... ©� �0�...I...f.:.e':...)r.................. Date.... `. �� Test Pit No. 1....____ _minutes per inch Depth of Test Pit_.-.�_.....Sr._. Depth to ground water....r '— 44 Test Pit No. 2.........____...minutes per inch Depth of Test P.it._... . �._... Depth to ground water........................ O 2 cr•••` oo�w, 2 rr .Gle.c�h Yt� a� O Description of Soil_..........`__--•--:_- ._... .__ -••- ... . W ................•...................•--------------•-----------•...... -------------------- -.-- •-----____..---------•----- -••••• - x •--•-----•------------ .........................................•----------------------....--------------._.....--------------.-----•---.._..__._......•----.......-----•••••--•--............_......... UNature of Repairs or Alterations—Answer when applicable............................................................................................... Arsigned --------- `.. Agreement: .� �? The un agrees to i ll the aforedescribed Individual Sewage Disposal System in accordance with the provis• us of'I'1'M 5 of the State Sanitary Code—The undersigned further agrees not to place the system in pe ation u til a e ificate of Compliance has been issued b he board f heal igned.....'214, .. ... .. ..................... ............. ................ ' i�(� - Date . Application App oved B --••-- -•-••-- ..G.._ll , `� ??1 �� y...... Date Application Disapproved for the following reasons:-----•------•-•--•--•-•----•--•--•.....................•----...---------•--------•---...._----•---._........... ...............•---.......---•-•-------.......---•-•-----••-•.---.._._..........__...---......----...---------........_--••-•-•-•---•---._._........-•-•-----••---......-•---.... __......... Date PermitNo...................................-...................... Issued........................................................ Date =N .......... Fxs... «.._. THE COMMONWEALTH OF MASSACHUSETTS. BOARD OF HEALTH r ,� �owh C�arns�0.�� .......0 F.......................................................................................... e Applitation for Diapoattl Marks Tonatrurtion Permit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System ad •Location-Address or Lot No. . .......... ............... ................. ..---••-••................................ -- -•-••----•----................................ Address wner _+ t/0 A ss `7 ............... . , ..................------- .................... •.....------ Instal e Address Type of Building i Size Lot ........................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of ersons....................:....... Showers — a YP g ..................•--------- P ( ) Cafeteria ( ) QOther fixtures ----------------•---•--....................................---•--.......---....•......---.....------._._...._............................. W Design Flow............. 5.......................gallons per person jr day. Total daily flow........ .................................. lon Septic Tank—Liquid capacityAO°<>gallons Length. ?.. Width:. ' ... Diameter................ Depth_. .e W Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No__ ________________• Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (x) Dosin tank ( ) Percolation ,Test Results Performed .:......................... Date....b.5.1z�........_. � Test Pit No. 1... -.:..minutes per inch Depth of Test Pit....144..-. Depth to ground water.... e 44 Test Pit No. 2................minutes per inch Depth of Test Pit....1�. :....... Depth to ground water.....e:hS' v'v x 1. .............................. . Y r ..... 0 0 2. �ola�, � Svbso��....2� - 1�-.... Gleah ► ;e q� Description of Soil__..... ;... ,. ................... See. a c 4;e d----I--� .......................... ...................•--•-•------------------------•---------....------......--•---------------.....•,------------------................-----.............-•••••-•-•---•--..... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ................ .--- ---------------------- - --• ----------------------------• •-------- Agreement: — � t The un/r-signed agrees to in`tall the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T Uf- 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be6411, enn issued b he board f heal eN igned.....--�, r � :f.+.a•.w,•q..�.-: • --•---•... ..........1.3 Da�te/.. Application Approv By........_: ... .. ... ....................... ............... ......_. 7 e {' Date Application Disapproved for the.following"reasons: - =-------------••------••-------•--•-•------•-------•------------------------•-----------------------••-- .................`..............-----•••------••----•-•-••. ... --•-_- •--.'.._......-----..............---------•----••--•••...........-•----••....... Dater..... .. PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS 130ARD OF HEALTH .........................I................OF..................................................................................... CIrrtif iratr of Tomptianrr THI IS TO CERTIFY, That the Individual Sewage Disposal System constructed A�`oi�Repaired by........ t : t......._:j.4- .ca . ............................: --------------- -.............. -...........---......---•-•......•..n........................................ at........�1_---5...............................................................� y� 1 ` j Installer ........ ..........................•-----•-------•---•---.....--••-•-•---....------•----- has been installed in accordance with the provisions of TIT R. 5 of The State Sanitary Code a desc ibed in the application for Disposal Works Construction Permit No ...... dated..........1 > S� THE ISSUANCE OF THIS G�0TIFICATE SHALL NOT BE CONSTRUED AS A GUA NTE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � t-/' .f r (.,fit, DATE.........••---6 1 S? f 9_S �, �I ........... . •--•-------•--- Inspector .............................. ----- THE COMMONWEALTH OF`MASSACHUSETTS 'BOARD OF HEALTH / No...�.? ..'._�:�C�1 ........... �...-O_ _F.u._..... F> aJ... 1DixVo ark ( natrurtian Prrmit �- Permission is hereby granted...... Lr' . ----....G -----------_-------•---.............................................................. w to Construct ( ) or Rep it ( ) an Individual Sewage Disposal System f Street C �r as shown on the application for Disposal V1'orVsfonstruction^fie rmrt No.^.�..a................ Dated...._..i l .�`��..._..._........ CJ LBoard of� DATE.. Health �� r ......-•........... .......t.....-•-------•-•--------------------- J- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppitcatiori for Miqual *pgtem Com5truction Vermtt Application is hereby made for a Permit to Construct( )or Repair(Ian On-site Sewage Disposal System at: rL catiodress or Lot No. f�Q 5 U/14� Owner's Name,Address and Tel.No. 'S�4Iap/Parcel - a d+ /� JU�i tS/V Installer' ame,Address,and Tel.No. �d /¢�/�� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �3 3D gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) --T--1N 5'T-m I D 6�, UJ 1 a / S t DIVA Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue oar k,� - Signed Date — 9` Application Approved b Dater d �o Application Disapproved for the following reasons Permit No. /1 Date Issued N0. , Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS t Z[PpYication for 0i0pogal bpgtem Construction Permit Application is hereby made for a Permit to Construct( )or Repair(Looloan On-site Sewage Disposal System at: L c3atio dress or Lot No. 5 w)ql Owner's Name,Address and Tel.No. ' 4 s A r' ap/Parcel �7 hl�/ C_ U 6�/1/ Installer' Name,Address,and Tel.No. oil . i9}tlCr Designer's Name,Address and Tel.No. Type of Building_: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures " Design Flow �r gallons per day. Calculated daily flow 3 3� gallons. Plan Date Number of sheets Revision Date Title Description of Soil x Nature of Repairs or Alterations(Answer when applicable) IN 5-T-AA � �1 I d t K,_ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue _ „thi, oard o i Signed Date c 16 Application Approved b Date 77 6 Jf Application Digapproved for the following reons 4, Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance S I TO CF that the On-site Sewage Disposal Sy terninstalled( )or repaired/replaced(t/ by ✓ N44fLADe AS Installer S vq&e e at siA_-,A`:71— has b en constructed 'n acco nc ' with the provisions of Title 5 and the or Di posal System onstructi tr'Permit No. d ed 7" Zd' Date /-"� =�— � Inspect f7 , THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. — IIL �✓'— —------------ ---------------�— Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS dig ogal �pgtem_ on!tructton Permit Permission is hereby grantego cp -e, pe'✓1s to construct( )repair(0 an On-site Sewage System located at No.# to of ST Street and as described in the above Application for Disposal System Construction Permit. o. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All constructiorCmp5t be completed within three years of the date below. Date: Approved by --Board of Health 7 q- . - # _ •` In. - e ♦ j. _,.I.I ° �• � I+ r ' , 1, ,`' + � 4 raa a. n� ," ' •� ... ' _ .i - r^ - l• .• ' ' 1 - •f 4 ,�l". F 4•- , ', ,, " 1. 4' S A .. �,. .,:: a .. a ' .'•i . . ,1,. .. .. SECT, N.- SEWAGE . i SEPTIC TANK — — :'D++BOX — 'LE Alt FI P1`` ' I. T • • ar. TOP OF FON'I t + + (MSI)w 11211 OF11ST a 4 t 0, ,1 1N'IISHEO STONE n • Ti N Q'. ` OUT IN OUT. + l Si IN oo G �y .. ,.1�L►�•6.;1 ., a SEPTIC ��.yy,, ',_. •- , ff ;�� .�. /.. .. .� � .. - �1 7o", 6TITANK l l0�5 a« tIF% ELEV: eay ELEV! ELEV, °' • Y" 't' .A ELEV. 1 + ELEV. ELEV. ,. s OF 3A 1Vf! y 4 - ` WASHED STONE TEST ,HO 'QG TEST BY A.'Q,3J� r� ,wpye. G. D�c4-lESt,aEY_ �• Isy Q , WITNESS. TEST..DRTE .; ,' � ' - DESIGN =BEDROOM HOwsE <T.H. ►`1 - r T.K. 2 '° ELEV: i day ELEV. NO ft► • W \, . 4 DISPOSER's, a — DISPOSER SOS O • P � MIN IN. , • r ERC RAT. / 1A ..1 n � < %iZ o FLOW RATE 'pjl*jCw GAL./DAY) 3"v ar t :d► SEPTIC TANK ' Q. ((• _ . "<. a>Q ¢?; - p . �EQ'DSEPTLC TANK SIZE lcicc • � clean $ .. Scvicl s�'s r:s ko"I co LEACH FACILITY SIDE WALL PZ:�'f! 'b►� .lt'S`��?.n;,:► 'a- 'ZAP GCD. 7 • BOTTOM 1 Z'z '�/a ��'S'L" r 'G/G. •r TOTAL ZZ,(d S.1~. �Y /i� r `o _.o 'roql 'USE: 0"'p. LE;4GWING WATER ENCOUNTERED. _ y / J �+�^'�► NOTES! (UNLESS^OTHERWISE- NOTED) 49 1.DATUM(MSL)+TAKEN FROM ` J ____QUADRANGLE MAP 2.MUNICIPAL WATER A_.._,._ _�.rs1 ..._......__AVAILABLE 3.'PIPE PhTCH Mi'•PER FOOT 4.,DESIGN LOADING FOR ALL PRE-CAST UNIT$:AASHO• T t0 -44 Q ARNE H. �: � ---�---DISTANCE AS CERTIFIED S.MIN.GROUND COVER OVER ALiP SEWAGEyFACILITIES: (1),FT. +�f ^+ 6.PIPE JOINTS SHALL B'E MADE WATER'TIGHT' � O.fALA -4 P ' 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. ca 'CIVIL V STATE ENVIRONMENTAL CODE TITLE 5 Ncl 307 ! ' SITE. A r �._ 5 t>w• '25'y Zcr'v� � >�,�.,. — �!'1•.1 '' q - • Locus • _ A17?V bT �'ti •co �"r `r h • - • w A' N�•T S• tlaa�..� AIRo S tl.6x.'t"` r -A- • SIONAL ENGINEER, � , I REF: —Cj"1" 'S �•eSS�nahiR�t., L. 'C '}:." ` -\46, alawn +rode VVIRe� � gt :3 PREPAREDFdR «f✓MAP��S*�UIGI"{ NE • CIVIL 'ENGINEERS.' t 4 ? o(Io-ow v • \:.L:. Gt+l1"cR� " � ► ¢ LAND'SURVEYO.RS } `BOARD OF,;IEALTF( Q IIl1,* ip_ REG:.LAND SURY VOR' !1 _..._ 1 r '.f. w SCALE � ►. O.3d TOUR$ :(EXISTING) P VED F. AiNS` !3l:E MA VA 'y. °t P ,; t, *rs ON AP RO DAT S:C E TE j.PROPdSEO)--O—br-C} — _ ry t Lt "e . r".