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HomeMy WebLinkAbout0124 PRINCE AVENUE - Health 124 Prince Avenue, Marstons Mills V7 f L i o r Commonwealth of Massachusetts Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P' 124 Prince Ave. u Property Address David Hobart Owner Owner's Name ./ information is Marstons Mills V Ma 02648 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information D on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 - . 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 Brett Hickey Dareazozoiii608:38: osoo• 11-12-2020 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. t5insp.doc•rev.7262018 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 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-12-2020 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: The system was in working order at the time of inspection. Cottage and main house share the same SAS. 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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 e , Commonwealth of Massachusetts - Title 5 Official Inspection Form I- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is Marstons Mills Ma 02648 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: l5insp.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 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �p 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-12-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a 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 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is Marstons Mills Ma 02648 11-12-2020 required for every 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 ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ El Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ R The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1- I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is Marstons Mills Ma 02648 11-12-2020 required for every St page. City/Town ate 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 C.4 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 El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ El Have large volumes of water been introduced to the system recently or as part of this inspection? E] ❑ 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? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? ED ❑ 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? ❑ E] 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ El 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 ~ 'ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-12-2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3(2+1 in cottage) Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 348/GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes 0 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 ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes CE No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2019- 57,000gallons 2018- 120,000gallons Sump pump? no Yes ❑ No Last date of occupancy: currentDate t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form 1~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is Marstons Mills Ma 02648 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA 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 If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 2019 Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is Marstons Mills Ma 02648 11-12-2020 required for every 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. El Other(describe): (2)septic tanks, pump chamber, D-box and SAS Approximate age of pp g all components, date Installed (If known)and source of Information: 2019 per COC Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑cast iron ■❑40 PVC ❑other(explain): Distance from private water supply well or suction line: Town waterfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.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 �~ i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is Marstons Mills Ma 02648 11-12-2020 required for every page. City/Town Satet Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: 9 concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 and1000gallons 1st 6" 2nd 0" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 1st 30" 2nd NS Scum thickness 1st 3" 2nd NS Distance from top of scum to top of outlet tee or baffle 1st 6" 2nd NS Distance from bottom of scum to bottom of outlet tee or baffle 1st 14" 2ND NS How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both tanks were in working order at the time of inspection and are not in need of pumping at this time but should be pumped every two years for maintenance. One tank services main dwelling and the other services the rear cottage. t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is Marstons Mills Ma 02648 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: NAfeet 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 r 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: NA., Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Offdal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is Marstons Mills Ma 02648 11-12-2020 required for every 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? El Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): oilDepth 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.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is Marstons Mills Ma 02648 11-12-2020 required for every 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: 9 Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber, pump and alarm were all in working order when viewed. 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: (2)500 gallon chambers El leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form ~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is Marstons Mills Ma 02648 11-12-2020 required for every 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.): The SAS was in working order at the time of inspection. Leaching was dry when viewed with no high staining. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of(Massachusetts @ Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave. Property Address David Hobart - Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-12-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):. t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 124 Prince Ave. u Property Address David Hobart Owner Owner's Name information is Marstons Mills Ma 02648 11-12-2020 required for every 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 "rFM CON MONWF.A!,:TH OF r4ASSACHUS,ETTS PUBLIC.HEALTH.DIV1Si(SN;BA NstABLEI'AIA SACHU57y1T"s ",�i c asal• reftitt,'Call teurtinn:�iermit aastorty tturaby l;rartted to Construct( ) Repair d6( ��. Abandon{ )... stattt ..t,.l. --- Xtt� , ...__.. ...... ---- "atja"as t1rs Rl§04 in tiia sib.Application for Disposal System Constroction Yertuit 'The r liplicant recognized hia0w duty to comply with Tula 5 attd,th¢,-folXRwing local provisions yr special conditions. s fh°ovuiad S"onstntc" must be compicted within three years of tho date of dvs pemtit ^'• "" - 17'nne APpteved..by_ --..,,:.�"- TOWN'OfF BARNSTABLE - ., LelcAT1oN t7-4- APt nos AVE SEWAG n 7 lit ram Q3 vn r sTti.Lft -----__..._rssEsst:R'sMAP st PA cFL '"It,.- 4 WsTA.LLER's NAME&PHONE NO. , ,♦ , '7i4� '�"-�''tCri'� "�"t�i O _ z r ncl rNQ FA cn rrir(type) 1 � ,NO.1F BE'[3ROOMS:. 'f.DWNFB Lc.is • to t" clo W mANCE VATI~ - Sleparacxon Dutaucq Between the .; ' � .. ° Ivfaoumum Achttscad Gmwidwater Table to the Bottom of Leacbing Facility Fact Ptivawe w'atar 8npply Well and La W.W Facility If any wells moist on si"a qr Wfihan 200 faet of le.tcfting facility)- - Feet Edge of Watland and Leaching Facility(If any wettarids exist within ,I Abb feet"f leaching facility) Fiat { FE fRNI5R3FX)f3X Ate.3 �".; 'Z-,z:z t , x ,C z�•�N' x ;. 44 �`��` ' �3'•# .�G .'�+•I'3s'G" 1r`F�or.7't' w CS-3a 4 I. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 C� Commonwealth of Massachusetts v'-' Title 5 Official Inspection Form Sk Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave. 96 Property Address David Hobart Owner Owner's Name information is Marstons Mills Ma 02648 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope Surface water Check cellar 0 Shallow wells Estimated depth to high ground water: No GW @ 120"feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record If checked, date of design plan reviewed: 3-21-2019Date ❑ 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: A plan on file at the local Board of Health was used to determine high groundwater. 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 l 124 Prince Ave. Property Address David Hobart Owner Owner's Name information is Marstons Mills Ma 02648 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: 0■ A. Inspector Information: Complete all fields in this section. �■ B. Certification: Signed &Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed �■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE LClyATION 12A Qbflcc AVE SEWAGE# ZO1a1 10� VILLAGE M, M,'10$ ASSESSOR'S MAP&PARCEL I t,- Y INSTALLER'S NAME&PHONE NO. 2,�3 EX CcLVy A. ;O r%- ( `1`l- OG53 SEPTIC TANK CAPACITY bSOO - 1000 LEACHING FACILITY:(type) 500 gal LIC (size) 13 x ZS x Z NO.OF BEDROOMS � OWNER ay irL to So ri PERMIT DATE:S'2S- 19 COMPLIANCE DATE: 3-Z S- 19 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 AI -3o' C1 131_IS l&', ,91 A CZ- Zz`. CQ Z �s j3Z' A3'y3� C3- 2l,2.. 3 B3- 25� fl3- 25 V Ay �9,�40 C,4' -�33'1,, FRo�-r O O CS-3° ' q CL DI, ' FO 19 :-] 2 u CO is F ° Ln r- r, ; E. CO Certi it Fee y.<< Er $ � E rvice5&F eakk 9Wd fee asap te) rl rn Recei copy) , Q rn Receipt(el le) $ - Postmark MOO Mail.. Here Signature Requlred gnature Restri i e;y U `rrr4 Posta qll- C-3 rn otal,:Po d DAVID F&BECKY B ,.u) sentrTo 124 PRINCE AVE � --pt.N.,of MARSTONS MILLS, MA 02648 Cl-�. Sheet and Apt No.,- Cif};State, Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this, delivery. USPS®-postmarked Certified Mail receipt to the'. ■A record of delivery(including the recipients retail-socmte n, signature)that is retained by the Postal Service'" estrict"e�es�rlAe� ich provides ; dell ry the adds a ed b for a specified period. �ry y name,or tftheaddressee'sauthoriztidl T Important Reminders. Adult signature service,which h the ■You may purchase Cert-ed Mail service with a signee to'be at least 21 years of ag%(not �p First-Class Maila,First CI Package Servi ; available at retail). or Priority Mail®service. a 7c -Adutt�ignaa��uur�e restricted delivery se,�rice,which ■Certified Mail service is notavailable for requiregtti ignee to be at least 21 y ears of age_ international mail. sand provides delivbry"'to the addressges eci ied J ■Insurance coverage is notavallable for purl i a byname orto the addressee's authorized agent with Certified Mail service.However,the pure ase (not available at retail). 42t-3 of Certified Mail service does not change the�' . .To ensure that your Certified Mail race p as insurance coverage automatically included witty accepted as legal proof of mailing; Oould bear a' certain Priority Mail items ' USPS postmark If you wouw,kea Mark on ■For an additional fee,and with a proper r this Certified Mail rec �pleas esem your - endorsement on the mailpiece ydu:;mey request Certified Mail item at;a Wbffice'"for =, the following services: postmarkidg.If you doa't nneed a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion of delivery(including the recipients signature). of this label,affix it to the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. ; electronic version.For-a hardcopy return receipt, complete PS Form 3811,Domestic Retum Receipt-attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records. PS Form 3800,April.2o15(Reverse)PSN 7530-02-000-9047 C ■ Complete items 1,2,and 3. 7XBP� ' nature ® Print your name and address on the reverse �� Agent so that we can return the card to you. ❑Addressee ■ Attdch this card to the back of the mailpiece, eceived by(Pr' ted Name) C. Date of Delivery or on the front if space permits. D. is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No Frb ART, DAVID F& BECKY B I -124 PRINCE AVE I' MARSTONS MILLS, MA 02648 II I IIIIII IIII III I II IIII III I I III'II II I IIIIlI III 3. Service Type ❑Priority Mail Express® ❑Adult Signature ❑Registered MaiITM Adult Signature Restricted Delivery ❑Registered Mail Restricted 9590 9402 4798 8344 8587 56 Certified Mail® Delivery ❑Certified Mail Restricted Delivery eturn Receipt for ❑Collect on Delivery Merchandise e,+i awr„o_ ., har_[Transfecfrom se )rvice label 0 Collect or,Delivery Restricted Delivery ElSignature ConfirmationTM ` ❑Signature Confirmation r— 7 015 1730 0001 4987 9538 Aail Restricted Delivery Restricted Delivery 10) n Form 3811,July 2015 PSN 7530-02-000-9053 Domestic`Return Receipt USPS TRACVJNG#. "'1 ^`t�`•E ;r�1iL"' First-Class Mail Postage&Fees Paid USPS Permit No.G-10 9590 9402 4798 8344 8587 56 United States Fsender:Please print your name,address,and ZIP+4®in this box• I E Postal Service —-- I : .:f Barnstable I I Health Division I .o 2,,n 0 Main Street Rvannis,MA 02601 I I I I I b s Dkrt Tkslkd Town of Barnstable Barnstable Inspectional Services 1 MUC KV an�rrs�raet�. M"M Public Health Division � �esq. �� m 200 Main Street, Hyannis MA 02601 2007 ,,,, Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL# 7015 1730 0001 4987 9538 March 4, 2019 HOBART, DAVID F & BECKY B 124 PRINCE AVE MARSTONS MILLS, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 124 Prince Avenue, Marstons Mills was inspected on 02/07/2019 by Brett Hickey, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH om McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\124 Prince Ave Marstons Mills.doc I - i r Y Town of Barnstable , N • 3ARN81'ABIE, • Regulatory Services Department Public Health Division__- 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA Gstatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc D4l(o—oo� Commonwealth of Massachusetts Title 5 Official Inspection Formt Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 124 Prince Ave Property Address t2 David&Becky Hobart Owner Owners Name information is Marstons Mills Ma 02648 2-7-19 . v required for every C 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. Important:When filling out forms A. Inspector Information on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Company Address Sandwich Ma 02563 city own State Zip Code (508)477-0653 S113747 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 Brett Hickey �a�.o, �1 �m� ��s 2-7-19 -Ual.:-9 V 13:31A2-0flp Inspectors 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 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �u= 124 Prince Ave Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every 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: 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 �o p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3 Further Evaluation is Required q ed 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: l5insp.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 u 124 Prince Ave Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every 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 an Y l PP � Y) 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 I 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 asses if the well water analysis, performed at a DEP certified laboratory, for fecal Y P Y , P rY 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 El ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a 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 124 Prince Ave Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every 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 ❑ Q Liquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E] 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. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. 0 ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well P PP Y t5insp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 h Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave u Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every 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 El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? Q ❑ Has the system received normal flows in the previous two week period? ❑ o Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ Q Was the facility or dwelling inspected for signs of sewage back up? [D ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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: Q ❑ Existing information. For example, a plan at the Board of Health. ❑ a 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.7r2612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary ry Assessments v 124 Prince Ave Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 2+1 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330/gpd Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes Q No Does residence have a water treatment unit? ❑ Yes Q No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes RI No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes Q No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2017- 53,000gallons 2018- 102,000gallons Sump pump? ❑ Yes 0 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 v 124 Prince Ave Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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 If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 7-31-18 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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 cf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every 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. El Other(describe): Tank, pump chamber, d-box and SAS Approximate age of all components, date installed (if known)and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 31 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Distance from private water supply well or suction line: Town waterfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave V Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Off Sludge depth: NS Distance from top of sludge to bottom of outlet tee or baffle 0„ Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts � 9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l; 124 Prince Ave v Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 L c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 124 Prince Ave u Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): over 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.): The d-box was in working order at the time of inspection but full over inlet invert. t5insp.doc•rev.R26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every 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: 0 Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber, pump and alarm in working order * 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: ❑ leaching galleries number: ❑ leaching trenches number, length: 330 rechargers El 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 c� Commonwealth of Massachusetts ,�p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave V Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every 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 was in poor condition. Field was in hydraulic failure at time of inspection. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 c Commonwealth of Massachusetts ,o Title 5 Official Inspection Form col Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA 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 la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 124 Prince Ave V Property Address David&Becky Hobart Owner Owners Name information is Marstons Mills Ma 02648 2-7-19 required for every 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 ]AT A1.20' 51.15' A2-W 82.31' 6 i Q C1.16' D1.28' C2.43' D2-44' C3.43' D3-49' C 2 00 3 p SAS t5insp.doc-rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I°I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑■ Surface water ❑■ Check cellar ❑■ Shallow wells No GW 4' below SAS Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 2-19-1997 If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file with the Board of Health was used. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 a -r c� Commonwealth of Massachusetts 1, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Prince Ave Property Address David&Becky Hobart Owner Owner's Name information is Marstons Mills Ma 02648 2-7-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ❑■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. d 4 (,O V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplifation for ]Disposal 9;pstrm Construction Permit Application for a Permit to Construct( ) Repair(,4 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.1Zt{ .Qri/�cc. AVC Owner's Name,Address,and Tel.No. DOLU, 1j, 140 jar'I Assessor'sMap/Parcel '7& IZy y-riACG AVE Installer's Name,Address,and Tel.No. ,$ E)(C<LWxAtO✓\ Designer's Name,Address,and Tel.No.FlQ jNcI-4 y E',V v;rO- W'TcgSc,rry L Q Forcmdalc 4n`1 •0GS3 _Po,9ox 331 /j�Lr-w'alp `7,ly 99y 11I I�pe of Building: Dwelling No.of Bedrooms 13 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 1:�30 gpd Design flow provided 3 gg gpd Plan Date- 1 9 Number of sheets Z Revision Date Title Size of Septic Tank /00 O- 1,500 Type of S.A.S. 2> 500 oa I L C 14 2 0 Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si Date 13-ZS- ) 1 Application Approved by Date f Application Disapproved by Date for the following reasons Permit No. Zoo - /Q( Date Issued 1 No. i Fee a THE;COMMONWEA TH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes . Yication for ':Construction Permit Application for a Permit to Construct( ) Repair(,,,X Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.12q .Pr',rNc C- A VC Owner's Name,Address,and Tel.No.��v Assessor's Map/Parcel "N I VA A U6 Installer's Name,Address,and Tel.No. Q r)(CaV�,O i,\ Designer's Name,Address,and Tel.No. 14T�a5zrry tr�J F"oresidlalc y-)1 O653 _pogoX 331 q_j_wjck 7,7y 9,q /ILI Type of Building: Dwelling No.of Bedrooms '� Lot Size sq:ft. Garbage Grinder( ) `v Other Type of Building No.of Persons °r Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) :13 fo gpd Design flow provided a q? gpd Plan Date— -` �t. t q Number of sheets "Z Revision Date Title Size of Septic Tank 00 0 • lSOn Type of S.A.S. -2:)�59C) Desciption of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si Date�3. �- Application Approved by Date -' Application Disapproved by Date for the following reasons Permit No. Z 1 q ( Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of (Comipliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(,4 Upgraded( ) Abandoned( )by ( F car,,,der,-�,t�✓� at�? �I j�r, n�AUK has been constructed in naccordance with the provisions of Title 5 and the for Disposal System Construction Permit No q I )T_ dated �3 12" Installer Designer �o #bedrooms Approved design flow gpd ..om ,.. The issuance of this permit shall not be�"onstrued as a guarantee that the system wil�~—nch -Date // Inspector _ ~-- ------------------------------------------------------------ -------------------------------------------------------------------------- 1 / of No. Fee�� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS - Misposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at J 7 � and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction'must be completed within three years of the date of this permit. Date 1:7!; /�,� o, Approved by _ Town of Barnstable Inspectional Services Public Health Division �srasi.s. �nss Thomas McKean,Director .9 i6 3 �� 16 6 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: a-79 Sewage Permit# Zo19- 101 Assessor's Map\Parcel_ '7G L4 'Designer: ), rA , t=rw,rn c-M a,- Installer: Q�13 Excmuo 4 t ors Address: Pc). Gay- 331 1-ao mx icl% Address: 14 Tcca1,Crrc{ LiQ FrC_TW0-1c- On_n-ZS-19 S 4�I3 Exemu_-%A i ors was issued a permit to install a (date) (installer) septic system at 12y rye c Aoc- based on a design drawn by (address) _Dasje. F'l o er A u dated n-21 - 19 (designer)` _I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10 vertical relocation of any lateral relocation of the SAS or any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in co i e with the to rms of the RA approval letters(if applicable) DAVID D. n( IYr1�C�SNP 02 " FLAHERTY,,JR. staller's Sigimtute) No. 1211 o �0/STERN / s�NITARtPN (Design s tgnature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. WoAdeptsWWALTMSEWER connectlSEPTICOesigner Certification Form Rev 8.14-13.DOC Commonwealth of Massachusetts Executive Office of Environmental Affairs ti`y Department of R FO Environmental Protectl �yo� g 19 Wllllem F.Weld p ITgB� 9 Tr xs ary Argeo Paul Cellucel Do uhs U.C,a.mor a miationtr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION C . Property Address: 1 iCt ?�,:,n G_ ./��� ' �'� Address of Owner. Date of Inspection: t _ ZL _c "t (If different) Name of Inspector. (--A 0;�-••� Company Name,Address and Telephone Number. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: C"Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails \) Inspector's Signature: ,��/!'L'✓�" Date: 7 The System Inspector shall su � 't a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and.copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: I t Check A,B,C,or D: A] SYSTEM PASSES: CI-1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection: Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal, hacked,structurally unsound,shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) I One Winter Street a Boston,Massachusetts 02108 a FAX(617)556.1049 • Telephone(617)292-UN �A�Pnnted on R"Ied Paper t SUB_ RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. I Vol Date of Inspection: ". Bl SYSTEM`CONDITIONkWfPASS ('Continued) Seaagee backup oi'4reeakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or1due,to-brokea,,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health ` broken pipe(s)are replaced obstruction is removed �. distribution box is levelled-or'replaced The system required pumping more thaw four time. b year:due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board;of Health): broken pipe(s},are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED.BY THE BOARD OF'HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. \ 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINEST AT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFk7 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•anarsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The systet has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. S) OTHER (revised 11/03/95) 2 r � 4 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: (�Z�( 1`�itd Lt-GiL Owner. La+f: Date of Inspection: �.--Lt3 l DI SYSTEM FAILS: I have determined that the system violates-one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or owspool. Discharge or ponding,of effluent to the surface of the ground or,rurfaoe 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 lEas than 6"below invert or available volufne is less than 1/2 day flow. Required pumping more than 4 imes in the last year NO we to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption stem, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is hin 100 feet of a surface water supply or tributary to a surface water supply. i Any portion of a cesspool or privy-is wit a Zone I of a public:well. Any portion of a cesspool of privy is within feet of a private water supply well. Any portion of a cesspool or privy is less than 1 feet but greater than 50 feet from a private water supply well with no acceptable water,quality analysis. If the well has n analyzed to be acceptable, attach copy of well water analysis for . coliform bacteria,volatile organic compounds, amm nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The folloviing criteria apply to large systems in addition to the trite above: The system serves a facility with a design flow of 10,000 gpd or greater System)and the system is a significant threat to public health and safety and the environment because one or more of the followiftg conditions exist: _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:- Owner. Date,of Inspection Check if the following have been done: v- Pumping information was requested of the owner, occupant, and Board of Health. N ne of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates . during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _As built plans have been obtained and examined. Note if they are not available with N/A. '—The facility or dwelling was inspected for signs of sewage back-up. L—the system does not receive non-sanitary or industrial waste flow _-�a site was inspected for signs of breakout. A.11 system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on ezisting information or approximated by non-intrusive methods. _The facility owner.(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTE„M�INFORMATION Property Address: I 4—;A.L t A Owner. LA t u Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g`�' allons Number of bedrooms:_ Number of current residents: C' Garbage grinder(yes or no): Laundry connected to system or no): Seasonal use(,yes or no):T„_; Water meter readings, if available: , ' ' Last date of occupancy: L%'.y ei COMMERC IAL/INDUSTRIAI- Type of establishment: Design t1ow:_pl1ons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (ryes or no)_ Non-sanitary discharged to the Title 5 system: (yes or no)_ Water meter available: Last date of occupancy: OTHER (Describe) Last date of panty: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) If yes,volume pumped: Qallo / Reason for pumping: /6Z L,y �s� •�—� TYPE OF TEM�c tank/distribution box/soil absorption system single cesspool Overflow ossspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: .L." Sewage odors detected when arriving at the site: (yea or no) (revised 11/03/95) 6 III , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C \ SYSTEM INFORMATION (continued) Property Address: �) `{ t�'�.t.✓�-e.� iE cJ-Z � `'` Owner. Date of Inspection: SEP71C TANK � (locate on site plan) Depth below grader � Material of construction:__concrete_metal_FRP—other(explain) Dimensions: '� y Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:,'` Scum thickness: n i Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, co n of inlet and ou et tees,or baffles, depth of liquid level in Telalion to outlet invert, structural integrity, evidence of 1 etc.) GREASE TRAP:_ (locate on site plan) Depth below grad�` Material of conf(truction: _concrete_metal_FRP_other(e:plain) 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: Comments: (recommendation-tor pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,otrnctural integrity, evidenceyL3e@kage,etc.) t (revised 11/03/95) 6 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION(continued) Property Address Owner. Date of Inspection: 71GHT OR HOLDING TANK_ (locate on site plan) Depth below grade:'` Material of construction concrete_metal_FRP_other(e:plain) Dimensions: Capacity: callons r Design flow: ¢aUons/day Alarm level: Comments:. _ (condition of inl toe,condition of alarm and float switches, etc.) . i DISTRIBUTION BOX_X (locate on site plan) Depth of liquid level above outlet invert: Ci Comments: .... - (note if level andfixtri1xition is equal, evidenot of solids caM9ver,evidence,of leakage' to or-ut of box, ) �� C-tie, PUMP CHAMBER (locate on site plan) Pampa is working orderayes 10 -_ Comments: (note condition of pump chamber,.oead"itioa of pumps and a naaoee,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t . PART C SYSTEM INFORMATION(continued) Property Addregr, 1 �( (�-'t-ve �� jA4-W�j Owner. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (Irate on site plea,if possible;excavation not required,but may be approximated by ton-intrusive methods) If not determined to be present,explain: TyPe leaching Pita, number: I •'` �G ti v ',,,r lasehing chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overilow cesspool, number: Comments: (note condition of soil, signs of by . ulic fail level 9f ponding, condition of vegetation,etc.) i CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to,b4et invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: \ Materials of construction: \ Indication of groundwater: inflow(cesspool must be pumped as of inspection) Comments: (note condition of soil, signs of hydraulic f ' �onding, condition of vegetation,etc.) PRIVY:_ •- (locate on site plan) Materials of cp tru�ction: Dimensions: Depthof Bs. C (note wadition of soil,signs of hydraulic failure, level of poading,condition of vegetation,etcJ (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ( `f Owner: L-Q," Date of Inspection: Z S— 7 -7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' r. -t r s r -1-- ; c�� c I � R - DEPTH TO GROUNDWATER Depth to groundwater: !L_feet method of determination or approximation: (revised 9/15/9S) 9 TOWN OF BARNS—1 ABLE D*THETO OFFICE OF DAfl119T6IL w� BOARD OF HEALTH BL i r�ee. � 'oo 039. `em 367 MAIN STREET aMAI HYANNIS, MASS.02601 February 20, 1997 Peter Sullivan, P.E. Baxter&Nye, Inc. 812 Main Street Osterville, MA 02655 RE: 124 Prince Avenue, Marstons Mills Dear Mr. Sullivan: Your request for a variance on behalf of your client Lawrence Catusi from 310 CMR, 15.253 (1) (2) to install only one six feet by six feet (6'x 6') leaching pit in order to repair the onsite sewage disposal system located at 124 Prince Avenue, Marstons Mills, Ma, was not granted. One leaching pit does not provide enough leaching area required by Title 5. A three bedroom home soil absorption system must be designed with a total of 446 square feet or more. Section 15.2053 (1) (2) states: "A maximum of two feet of sidewall depth below the invert of the inlet per leaching pit shall be used when calculating the effective leaching area." One leaching pLit with the maximum of four (4) feet of stone, provides only 242 square feet. Therefore, two leaching pits are required. Variances shall be granted only when, in the opinion of the Board of Health: (1) the person requesting the variance has established that enforcement of the provision of Title 5 from which a variance is sought would be manifestly unjust, considering all the relevant facts and circumstances of the individual case; and (2) the person requesting a variance has established that a level of environmental protection that is at least equivalent to that provided under Title 5 can be achieved without strict application of the provision of Title 5 from which a variance is sought. In the opinion of the Board of Health, you did not establish that enforcement of the provision of Title 5 from which a variance is sought would be manifestly unjust. catusi Also, a leaching system designed and installed in accordance with Title 5 (1955 code) would disperse the effluent over a larger area, rather than concentrate all the sewage effluent into one small area. Dispersion of sewage effluent over a wider area provides a slower application rate of the effluent into the soil, thereby, providing additional time for treatment of the sewage effluent before it percolates into the groundwater table. You did not provide official information that the same degree of environmental protection will be achieved with the use of one leaching pit. Therefore, the variance is not granted. Sincerely yours, / MhQe . Susan G. Rask,-�K.S. Chairman Board of Health Town of Barnstable SGR/bcs catusi i TOWN OF BARNSTABLE L.C,:ATION ce.- SEWAGE # q Y'fLLAGE -,-rk ASSESSOR'S MAP & LOT - 645 INSTALLER'S NAME&PHONE NO. a SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER Cta PERMITDATE: 71 _ 1 7 9 7 COMPLIANCE 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 leaching facility) Feet Furnished by Teti 0 0 3 g �.v 4 Lj No. C/ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 1/ 0[ppYtcation for Mi!gpool *pgtem Cottgtruction Permit Application is hereby made for a Permit to Construct( )or Repair(<)an On-site Sewage Disposal System at: Location Address or Lot No. j� Owner's Name,Address and Tel.No. Z.A I..A VU1-GIUC.c� CFI%U3 I 2.A ea." "-,(_L�S Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. AZS-%3 r l2 t'�l/act u17 S T C>--r Type of Building: COc Dwelling No. of Bedrooms Garbage Grinder( � Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1�0 gallons per day. Calculated daily flow 1 t gallons. Plan Date Number of sheets CO Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d by th' and ealth. Signed Dat 9-/, Application Approved by 'T 1_4 — - Application Disapproved for the following reasons Permit No. 7=:7v Date Issued 144* No. Fee i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Migogar *pgtem Congtruction Permit }, Application is hereby made for a Permit to Construct( )or Repair an On-site Sewage Disposal System at: s Location Address or Lot No. Owner's Name,Address and Tel.No. 12_4� v C- �.��•c�9-c �Z q+?2� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.` 2$:9\^ ' Ili[, ,� Type of Building: cc) Dwelling No.of Bedrooms Garbage Grinder(4 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i " Design Flow t0 gallons per day. C, lated daily flow N ,0 gallons. Plan Date \2 -&91 wo Number of sheets Revision Date G�\9197 Title `Y,LC> c./,,N LA C 5 Description of Soil 1., Nature of Repairs or Alterations(Answer when applicable) 7 , 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 iss d b thi and ealth. Signed Date : Application Approved by �,d...�._ _ 7 Application Disapproved for the following reasons I Permit No. 7 7— 7 y Date Issued r THE COMMONWEALTH OF MASSACHUSETTS "" ..,, PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS u , I Certificate of (Compliance - THIS IS TO ERT. tha the On-site Sewage Disposal System installed( ")or repaired/re laced( )on by a r sl/s .p.' for .40 sV*tee er 7'4 .fJ t as <--, - 'ow -7-4?4 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated ' V41 + '7 Use of this system is conditioned on compliance with the provisions set forth below: No. 11 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS i 1wigpogaf *pgtem Congtruction Permit Permission is hereby granted to /� 41zf yo, to�ct,( e )repan-site Sewage System located atv/ 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. All construction must be completed within two years of the date below. Date: i/ / / / Approved rq A2 t 1 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) M A- �C&' -L 7- 7 DATA TOWN OF BARNSTABLE LOCATION SEWAGE # `J 77 VILLAGE � -rl I�� I�� ASSESSOR'S MAP & LOT - Q4 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 1 j— (size) NO.OFBEDROOMS BUILDER OR OWNER G&� PERMITDATE: :) - y 7— U 7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (!f 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 0 0 0 -)c-0 4 �, k1 NO. TOWN OF BARNSTABLE DATE "'�� ` Z f INC OFFICE OF FEE } 111ur9T,ac i BOARD OF HEALTH RECEIVED BY Mil 1679. `{� 367 MAIN STREET • Y HYANNIS,MASS.0M1 VARIANCE REQUEST FORK ALL VARIANCES MUST BE SUBMITTED FIFTEEN (15) DAYS PRIOR TO THE SCHEDULED BOARD OF HEALTH MEETING. NAME OF APPLICANT �Avdgswc& GAT'usl TEL. NO;: ADDRESS OF APPLICANT (24- Fw uG'E AkJF— 44aMst A41L,14 NAME OF OWNER OF PROPERTY SA-tM y __ SUBDIVISION NAME DATE APPROVED ASSESSORS MAP AND PARCEL NUMBER 44AP -7b �cL Q- LOCATION OF REQUEST FZIA6 ' A✓6 114te6Ty'JS �It.LS SIZE OF LOT Iqj IF 'SQ.FT WETLANDS WITHIN 200 FT.YBS NO VARIANCE FROM REGULATION(List Regulation) IVWlj OF YAIZ L,5 250 A415 S& 7 70,0 >o — A2, !.f¢ REASON FOR VARIANCE(May attach if more space is needed) Zlw[^f 1-63W--tV Ale 61R6WAb9- 7v PLAN — FOUR COPIES OF PLAN MUST BE SUBMITTED CLEARLY OUTLINING VARIANCE REQUEST. VARIANCE APPROVED NOT APPROVED REASON FOR DISAPPROVAL BRIAN R. GRADYt R.S. t CHAIRMAN SUSAN G.- RASR, R.S. JOSEPH C. SNOWt M*D. BOARD OF HEALTH TOWN OF BARNSTABLE No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Migpo!5al *p5tem Cow5truction Permit Application is hereby made for a Permit to Construct( )or Repair( ✓)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. (� Re,WCE- ,QV� L1s-W acWGE r-A-TU5 I FzIn1cc ,4.vs lyfAeswms Mlux, AIJA&STVn6 nit it-,c_S Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 'BAXTE_--F_ 4. IJye W- 81'z M 4114 57- OS lc�� Type of Building: Dwelling No.of Bedrooms Z- Garbage Grinder( ) Other Type of Building6brrA6- -- I No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 30 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date f-='FJ3 3 }I q q I Title FLgr O.Aij you of p:wrtord Pile [-_V2 1Awq.L:3Jo_ Ck-us Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/rep]aced( )on by for as has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1=igpo!5a1 *p5tem Construction Permit Permission is hereby granted to to construct( )repair( )an On-site Sewage System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: Approved by No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,MASSACHUSETTS' ZIpprication, for Mioogal. *proem Congtruction Permit Application is hereby made for a Permit to Construct( )or Repair( ✓)an On-site Sewage Disposal,System at: ~� Location Address or Lot No. Owner's Name,Address and Tel.No. 4 ; (,� pe,uce- Ave Ldyu rzesiac ca n I WeS OMS Mlus All A96 ►4!� nit 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. -BAXI-1:m- 4. d y s IV, Type of Building: Dwelling No.of Bedrooms Garbage Grinder t' .t.Other Type of Building � No.,,gf,Persons s` "'""'"'� —Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 30 gallons per day. Calculated daily flow 370 gallons. Plan Date p�G'' F` I4&o Number of sheets Revision Date r__6r3 3 , 14g7 eW - Title Pcor RAN 5t4c 11j11 TD-_,r ron Ali* SsPrL_ SYSrL= QP&2Avt_ P 2 lAwali;;JC Q,-V Description of Soil Nature of Repairs or Alterations(Answer when applicable) � n Date last inspected: Agreement: yx 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- cateof.Compliance has been issued by this Board of Health. ` Signed Date Application Approved by Application Disapproved for the following reasons e Permit No.. Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance - THIS 3S TO CERTIFY,that the On-site Sewage Disposal System installed( .)or repaired/replaced( )on by for , as - has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: t No. " Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH'DIVISION - BARNSTABLE, MASSACHUSETTS Wi,5po.5a[ *pgtem Construction Permit i Permission is hereby granted to - to construct( )repair(• )an On-site Sewage System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions.or special,conditions. All construction must be completed within two years of the date below. Date: ' Approved by Town of Barnstable P# Department of Regulatory Services ( BAM M8 Public Health Division Date b 10 l MARSL �&69. 200 Main Street,Hyannis MA 02601 " lfC MA't C"a Imo/ ��ti Date Scheduled / Time 1_ fPd. _rl _ h• Soil Suitability Assessment for Se Disposal V Performed BY �•�f R Pd^[ �� J Witnessed By: LOCATION& GENERAL INFORMATION Location Address Owner's Name Address S'� Wt e Assessor's Map/Parcel: —7 V ` D Y Engineer's Name �y NEW CONSTRUCTION 1W REPAIR Telephone# Land Use Slopes(%) 3 —S Surface Stones H Distances from: Open Water Body /7,0 ,—ft Possible Wet Area '7/OCR ft Drinking Water Well ft Drainage Way r ft Property Line �� ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&-perc,tests,Socate wetlands in proximity to holes) zz Oki IF � r Z"� -mow►.� t ,� C?v-r > 3 17V ' Parent material(geologic) �� � "t Depth to Bedrock _ .-_ - .-_ Depth to Groundwater: Standing Water in Hole: �� ___—_ Weeping ft'om Pit 1711ee Estimated Seasonal High Groundwater �d r OETERMYNATION FOR SEASONAL HIGH WOERIAHL Method Used: _ Depth_Observed standing in obs.hole:_.a� in. Depth to Bell mottles: in. 9 Depth to weeping from side of obs.hole: ln. Groundwater Adjustment ft. Index Well# Reading Date: Index Weli level __ Adj.factor _.----_,. Adj.Groundwater bevel PEItCC3I,ATON TEST Observation Time at 9" Hole# Depth of Perc 30-9V Time at 6" Start Pre-soak Time @ tv'00 _— Time(V-6")_ End Pre-soak �'70 /r��Gh Rate Min./inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel /f -Z6' - few L5 Ewa/ i DEEP OBSERVATION HOLE LOG Hole# 7— Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel n—` z ,¢F ,a L5 � r - ?/ 1 Z- LS L S l v Y4 s/p Z S-!LU G/ A-'L SA,d Z.T- Y Gq sant , ISM ✓�"VG/ 6 o fG ' P �G DEEP OBSERVATION HOL LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, o Gravel) Flood Insurance Rate May: Above 500 year flood boundary No_ Yes Within 500 year boundary No— Yes Within 100 year flood boundary No— Yes Deyth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? < If not,what is the depth of naturally occurring pervious material? Certification I certify that on Z (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required trainin ,expertise and a rience described in 310 CMR 15.017. Signature Date Q:\SEPTIC\PERCFORM.DOC I 14OapION SEWAGE PERMIT=N0)orl' t4 il _e a VILLAGE 6c� A & B CESSPOOL SERVICE 128 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER 5 DATE PERMIT ISSUED �j© / 7 7 DATE COMPLIANCE ISSUEDR/ /7 lq. ve• v.169y H 26 gy / r So-v'fh wesf S;de pY• �ov 5 e - r• -------------- No ...84--.702 J $ 15.00 F>�a.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town Barnstable ........................__........---.....O F.........................................----------------................................ Appliratiuu for Disposal Works Tonstrur#iun Funfit Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal System at: .12.4..Prince..Ayianue,--1`laxstcs..dills....-M.....02648.............................................................................................. Location.Address or Lot No. .La rJotence - Caty ........................................................ ..4a3,7.-Maxi na..Ci tyt.Ilx_.,..Iiar-:L a,.--dal..Rayd...CA 90291 Owner Address aA B Cusp.Qnl_.Sesvi.c ,..lric............................... ..a28..B�hops..Te=aQP.,...Hyaxlnls,..BA.....Q26QI... Installer Address UType of Building Size Lot............................Sq. feet .� Dwelling—No. of Bedrooms..........2...............................Expansion Attic ( ) Garbage Grinder ( ) �'4 Other—Type T e of Building No. of ersons............a............. Showers YP g ---------------------•------ P ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------•---------.-•-•--------------------------....---------------•--------------------•------•---••-----------. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.... -----------------•--•-•------------••--•----------•-••-•---------.... Date........................................ 1.4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water....------.............. (i, Test Pit,No. 2................minutes,per inch Depth of Test Pit.................... Depth to ground water........................ a ------f------------------------------•---•--•-----------••-----------.--.....--------- ••----------------------------------- ------------ -.......... Description of Soil..............Sand x . UW --•--------------------------•------------••=----------•-------------------•-•-------------•-•---------•-• Septic Nature of Repairs or Alterations—Answer when applicable.installation of a 1,000 gal. , pre-cast, � gKKKKaxi U tank, d- Box and a heavy duty leach pit, stone packed. ------------------------ -..................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued by the board h lth. d ----- ....�.. ------------ ----Alf. . -8/.17/`* ...... Djte ApplicationApproved By.......... . -•-• •••••--•---------------------------------•--•.............---.............-- ----------8/177 ............ Date Application Disapproved for e f owing reasons:--••------------•-------------------------•---••••---------••--------•---••-•---------•.......----•••........... . .................... .......................................Date--•--...------ Permit No.....�L...--•....................................... IssuedL.......8/1718y_............................... Date e ,..7 C 90.......$4-_. .::. Fmc... ... ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town...........o F.............Barnstable -- • .................•---..................------•••-- ApplirFation for Disposal Works Tonstrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: -124--,pzUcG•.Av4r+u&,...Namtms--. -----026*...........................................•--••---•-----•------...........---............----- Location-Address or Lot No. la=�nca _..C.atU,sl .... VA. 90291 Owner Address a ,A--&-- --Cos�pool--S uicae ---I=----------------------•-..------ -l2a-.Bishapa..TErMeaL,..Hyannis,...MA....0.2{Ql... Installer Address Type of Building Size Lot----------------------------Sq. feet I—I Dwelling—No. of Bedrooms..........7...............................Expansion Attic ( ) Garbage Grinder ( ) �`•1 Other—Type T e of Building .__...._ No. of persons .............. Showers YP g -•------•------•---- P ( ) — Cafeteria ( ) Otherfixtures --------------••--------------------...--------------•---•••-•-••••---------.....••-••--•••--......-•--------•------ -•---- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -•-------•-•--------...•-•-•---------•-------••---•-••----------•••-••--•----•-•----•..............•......................................................... 0 Description of Soil..............Sand................................................................................................................................................ x Se is U Nature of Repairs or Alterations—Answer when applicable installation of a 1,000 gal., pre-cast, dX �( $�C tank d BOX and a hea-� duty le ach pit - ..._... l ----------•-------------------- -----••-- ------ .....stone pa � cked» Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I11 LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued by the board,.flth. , Sig 1�e� �� ........ �. - R1171 ...... , ApplicationApproved BY z f --------------------------•--••-•--------.............--••--••------•----•-- -•---- $1 1°`a------------- i Date Application Disapproved for e f o owing reasons:-•-•--•----•-•---•------•--•-----•---•--•••----•-•••--••---•--••--•-----...---•--•............................ ....................................................... -------•-•••••--•-•---•....----•----•-•-----------------------••-------••----------------------------......--------------------------.....----- DatePermit No.----o=-".......................................... Issued......8!/-i7/ .............................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................T-Wn..........oF......BaMetal e.................................................... Trrtif irtttr of TontlrliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) r Repaired ( X) by----A__&_B-Cesspool_-Service.- inc.---•-•----128_ Bishops•Terrace, Hyannis , MA---------(�601-------------- I t at......12� ..rino.. Ave., Marst ens P"ills j MA 8 Larry Catast has been installed in accordance with the provisions of T IF 5 of The State Sanitary Cod as descibed in the application for Disposal Works Construction Permit No.. .�_._:_... _.__f............. dated....._._._ /_ ......_...`_.__........_._...... THE ISSUANCE OF THIS CERTIFICATE SHALT. 1+10T BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................ �.... ./�:.-----••-•--•--•-••-----------•--.. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS J ; BOARD OF HEALTH J ` Town Barnstable .......................oF...................---..........._........---...-------••••--•....._................. 1 00 No......................... FEE..$....5-00..... Disps al Works Tonuirnrtion antit Permission is hereby granted.....A Ee B Cesspool Srvioe, Inc..................................... to`Construct ( ) or-Repair X ) an Individual Sewage Disposal S stem at No..----12�..��oe ve_., .AIarst c ns Mills,-14A 026�8 ---.Larry Catusi -----------------------------•-_..... Street as shown on the application for Disposal Works Construction Permit No.— ......... Dated.._...8/17/_84 .................... ......--- = ------.......................................................... DATE...................0/17/84 i Board of Health . -•-- FORM 1255 A. M. SULKIN, INC., BOSTON �,v COVERS TO BE WATERTIGHT AND TOP OF FOUNDATION BROUGHT TO WITHIN 6"OF FINAL GRADE SEPTIC SYSTEM PROFILE Flaherty Environmental Services COTTAGE:EL. 12.0' EL. 10.0' (not to scale) INSP. PORT W I 3" OF GRADE HOUSE: CLEAN SAND P.O. Box 331 L. 21.5' 2"of 8" to Z" DOUBLE WASHED , 4"CAST IRON or EQUIVALENT T' PEASTONrOR GEOTEXTILE EL. 20.0 Harwich, MA 02645 MIN. PITCH 1/4" PER FOOT FILTER FABRIC 774.994. 1166 4"SCHEDULE 40 PVC PIPE 4" SCHEDULE 40 PVC PIPE (H20D-BOX) VENT IF REQUIRED • FLOW LINE BlSt 2'10 bB/BVBI a'• 5' 1% <' • ' 8 6':.'•: L. XIST. e ---�—•— 14" � ®® . °ao°000°c EL EXIS °o°0°0°0°0° ° O C3 0°0°o°o°e Y. EL.EXIST. 0°00000°0 °000 .' o0000000c EL.17.53' °o°o° o°o°o°o° Q ®� o 0 0 0 0 0 0 0 0 0 0 0 " °o°o°o°oc EL.17.T o0 000.00°0°0 ��. ® °o°0°0°0°2_0 GAS BAFFLE EL.17.S' °000000000 o°o0 0 ®I ! 00000000 0 0 0 0 0 0 0 0 a• • 0000oo°°c • a "a •O0°o°o°o° EL. 15.5' •i O°O°000°O °O°O°O •�• 1 INSTALL INLET TEE ABOVE OUTLET INVERT SOIL ABSORPTION SYSTEM •..'• 1000 GALLON SEPTIC TANK (1) 1500 GALLON SEPTIC TANK 6"CRUSHED STONE OR (2) 500 GALLON H-20 CHAMBERS (DATUM: ASSUMED) (1) 1000 GALLON SEPTIC TANK (EXISTING) MECHANICALLY COMPACTED WITH 4' STONE AROUND IN A 5'$� (exisTlNG) f" to 1 ' DOUBLE WASHED STONE 12,83'X 25'X 2' CONFIGURATION BOTTOM OF TEST HOLE EL. 10.0' EL. 10.0' USGS ADJUSTMENT: N/A LOCATIONMAP 12 Ail GROUNDWATER ELEV: N/A N TH BENCHMARK: TOP OF FNDN 1 1 EL. 21.5' 14 1 Rt.26 16 20 `-- -------------- $ ------ D LOCUS 75�� EXISTING 0,41 ACRES± 1 BR DECK MAP 76 LOT 4 WELLING NTS I EXISTING EC EXIST, S.T. OFSS EXIS P.C. � i � 9 2 BR , ' DAVID cyG DWELLING SHED / \ Z cK HED / / / R H Y, vE 0 1 M $ 201' EXIST, S.T. i ' — FG/S T E ��\ O TH 1TH-2 ' O SgNITAR)P� m p i 10 Z i;'' DRIVEWAY �, DATE.3/21/2019 REVISED.' C O i m 1' 12 (� SITE AND SEWAGE PLAN FOR B & DAVZD HO ART INC. . 11.9' 16 14 AVENUE PROP, VENT REMOVE EXISTING 18 MARSTONS MILLS� i MA & REP INCSAMETAREAPROPOSED SAS 20 SCALE : 1 " - 3 0' REF.-DB 10647PG21 PAGE 1 OF2 :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ ............................................................................................................................ GENERAL NOTES DESIGN CAL CULA TIONS SYSTEM DETAIL Flaherty Environmental Services P. 0. Box 331 1. ALL PRECAST COMPONENTS TO BE H-10 Harwich, MA 02645 RATED UNLESS OTHERWISE SPECIFIED. NUMBER OFACTUAL BEDROOMS 3 774.994. 1166 DISTRIBUTION BOX(ES)AND ANY COMPONENTS WITH ANY ANTICIPATED GARBAGE DISPOSAL UNIT NO VEHICULAR TRAFFIC TO BE H-20 RATED. 2. THE DESIGN OF THIS SYSTEM DOES NOT TOTAL ESTIMATED FLOW ALLOW FOR THE USE OF A GARBAGE (110 GAL/BR/DAYX 3 BR) 330 GAL./DAY GRINDER, REQUIRED SEPTIC TANK CAPACITY 660 GAL. 3. MUNICIPAL WATER IS AVAILABLE. 2 S' 4, ALL CONSTRUCTION TO CONFORM WITH SIZE OF SEPTIC TANK S 1000 GAL. (EXISTING)X2 310 CMR 15.000 AND ALL OTHER APPLICABLE LOCAL, STATE AND FEDERAL SOIL CLASSIFICATION 1 ' CODES AND REGULATIONS. 5. INSTALLERICONTRACTOR TO REVIEW& DESIGN PERCOLATION RATE <2 MIN.ANCH VERIFY ALL ELEVATIONS AND DETAILS AND REPORT ANY DISCREPANCIES TO EFFLUENT LOADING RATE 0.74 GAL./DAY/FTC DESIGNER PRIOR TO CONSTRUCTION OR 12,83' LEACHING AREA '' ASSUME ALL RESPONSIBILITY. ` 6. INSTALLER/CONTRACTOR IS (2)x x 12. + 12.83)(2) = 20 SF 25.0'x 12.83' =320 SF RESPONSIBLE FOR MAINTAINING SAFE 471 SFx a74 =348 GPD WORK AREA, VERIFYING ALL UTILITIES AND NOTIFYING "DIG SAFE" USE(2)500 GALLON H-20 CHAMBERS WITH 4'STONE (1-888-344-7233) 72 HOURS PRIOR TO IN A 12.83'X 25'CONFIGURATION AS DIAGRAMMED CONSTRUCTION, 7, ANY CHANGES TO OR DEVIATIONS FROM RESERVE LEACHING CAPACITY N/A GPD THIS PLAN MUST BE APPROVED IN WRITING BY FLAHERTY ENVIRONMENTAL SERVICES AND LOCAL BOARD OF HEALTH. 8. FINISH COVER OVER COMPONENTS IS NOT TO EXCEED X PER 310 CMR 15.000 (NTS) UNLESS SHOWN PER PLAN. 9. ALL ABANDONED SEPTIC SYSTEM COMPONENTS TO BE PUMPED DRY AND SOIL EVAL UA TION FILLED WITH CLEAN SAND OR REMOVED TEST HOLE#1 P#15509 TEST HOLE#2 P#15509 AND REPLACED WITH CLEAN SAND. Evaluator- Glenn Hanington,RS Evaluator- Glenn Harrington,RS ZH OFSS 10,ALL COMPONENTS TO BE PROVIDED SE#1011 SE#1011 D 9 BOH Witness: Don Desmarais,RS BOH Witness: Don Desmarais,RS cr G WITH WATERTIGHT ACCESS PORTS Date: octoaerzo,2017 Dare: odoberzo,2017 0 WITHIN 6"OF FINISH GRADE. H . 11.ALL SEPTIC TANKS, DISTRIBUTION TH-1 ELEV.20.0' THZELEV 20.0' NO 21 BOXES AND PIPING TO BE INSTALLED — WATERTIGHT, 0"-11" AF/A LS f0YR3/1 0"-12" AF/A LS f0YR3/1 c�STER� 12,NO KNOWN WETLANDS OR WELLS WITHIN 150 FEET OF PROPOSED 11"-26" B LS 1OYR 5/8 11"-25" B LS 10YR 5/8 LEACHING. 13.THIS IS NOT A CERTIFIED PLOT PLAN AND UNDER NO CIRCUMSTANCES IS THIS PLAN TO BE USED FOR ZONING OR as" Pero SITE AND SEWAGE PLAN BUILDING PURPOSES. FOR 14.LOT IS SHOWN AS ASSESSOR'S MAP 76 B 8E B EXCAVATION, INC./ LOT 4, 26"-120" C MS 2.5Y6/4 25"-120" C MS 2.5Y614 DAVID HOBART 15.LOCUS PROPERTY IS NOT LOCATED WITHIN AN AQUIFER PROTECTION 124 PRINCE AVENUE DISTRICT(ZONE II). 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COMPLY WITH ALL GOVERNING CODES AND REGULATIONS. P.T SHALL IN PARTICULAR 310CMR 15.000 THE STATE ENVIRONMENTAL CODE TITLE 5. THE TOWN OF BARNSTABLE BOARD OF HEALTH REGULATIONS PART Vlll: AND THE BOARD OF HEALTH SEWAGE DISPOSAL REGULATIONS ON-SITE RECOMMENDATIONS FOR ACCEPTED PRACTICE. ON,, /'s 97 } � �x►S7 f NG G��crit_ .......... � 1►,ivs3. LC N �� � H -74 i(O :L.F l. T�G Ti'�4J l� pu MP -'�i ' �. t 5-r�cz� ._ I Nv•3,z>3 Z0b�)1 ` � /' ► Ga't'? € _ 5 wow-ro`(e 1� t--Al5-rl,., —T � TO #3E I ti ST1�L.LED t N S�GT \/n- ET.4,�'�T1t J �w \\ 4 �� I STf�X�Tt Oj ,yJ M — Pr-- —J:;uM'P lrav'i•��- / ALL �/ `�,� �j /�`I ,�I �`I X Co. CX�� 411J t S 00 18C_t-A X? Iz. 5 rS? \ / f STf:P '• � �` T]pCTI o t.1 t . 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