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HomeMy WebLinkAbout0048 WHITE BIRCH WAY - Health 48 White-Birch Way W. Ba(nstable 128 027' fJl a r Commonwealth of Massachusetts �028� Title 5 Official Inspection Form ®p� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 White Birch Way Property Address Matthew White Owner Owner's Name information is West Barnstable I✓ MA 02668 January 21, 2021 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 A. Inspector Information 5 # Ps �.. filling out forms on the computer, use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 Company Address Forestdale MA 02644 Cityrrown State Zip Code 508-888-6055 S112843 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 16.000); 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. E Passes 2. Q Conditionally Passes 3. 8 Needs Further Evaluation by the Local Approving Authority 4. 8 Fails January 22 2021 Insp�l'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.712&2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form F e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 White Birch Way Property Address Matthew White Owner Owner's Name information is required for every West Barnstable MA 02668 January 21, 2021 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" ( , 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 exf tration or tank failure is imminent. System will pass inspection if the existing tank is replaced wit a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection f it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is le s than 20 years old is available. ❑ Y ❑ N ❑ ND ( xplain below): i t5insp.doc•rev.726=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments j� 48 White Birch Way Property Address Matthew White Owner Owner's Name information is ry West Barnstable MA 02668 January 21 2021 required for every. , page. Citylrown 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 ut or high static water level in the distribution box due to broken or obstructed pipe(s)or due t a broken, settled or uneven distribution box. System will pass inspection if(with approval of Bo rd of Health): ❑ broken pipe(s)are replace ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is le led 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 a Board of Health: ElConditions exist which requir urther evaluation by the Board of Health in order to determine if the system is failing to prote public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 r ' c Commonwealth of Massachusetts Title 5 Official Inspection Form h a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 White Birch Way Property Address Matthew White Owner Owner's Name information is required for every West Barnstable MA 02668 January 21, 2021 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 HealthAand Public Water Supplier, if any) determines that the system is functioning in//a manner that protects the public health, safety and environment: j ❑ The system has a septic tank and soil sorption system (SAS) and the SAS is within 100 feet of a surface water supply or tribu ry to a surface water supply. ❑ The system has a septic tank and S and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and AS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank an SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply w **. Method used to determine distance **This system passes if the well w er analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent nd the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided t t no other failure criteria are triggered. A copy of the analysis must be attached to this form. i c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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.7126=18 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 48 White Birch Way Property Address Matthew White Owner Owners Name information is required for every West Barnstable MA 02668 January 21, 2021 page. Cityf town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15/ee 000 pd. For large systems, you musher" es" or"no"to each of the following, in addition to the questions in Section C.4. Yes No ❑ ❑ the sin 400 feet of a surface drinking water supply ❑ ❑ the sin 200 feet of a tributary to a surface drinking water supply the sted in a nitrogen sensitive area (Interim Wellhead Protection Areaa mapped Zone II of a public water supply well t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 White Birch Way Property Address Matthew White Owner Owner's Name information is West Barnstable MA 02668 January 21, 2021 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 aH inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 White Birch Way Property Address Matthew White Owner Owner's Name information is N West Barnstable MA 02668 January 21 2021 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD Description: Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ® Yes ❑ No If yes, discharges to: No Discharge Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Private Well 9 ( Y 9 (gP ))� Detail: Recommend removal of garbage disposal or yearly pumping. System not designed to handle. Sump pump? ❑ Yes ® No Last date of occupancy: Current Date t5insp.doc•rev.7/2 61201 8 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 48 White Birch Way Property Address. Matthew White Owner owners Name information is required for every West Barnstable MA 02668 January 21, 2021 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the itle 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Ready Rooter records: Pumped November 2020 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doo-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 White Birch Way Property Address Matthew White Owner Owner's Name information is required for every West Barnstable MA 02668 January 21, 2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Septic tank installed 1997. D-box and leach field installed 04/17/2012. Certificates of Compliance on file at Health Dept 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: feet Comments(on condition of joints, venting, evidence of.leakage, etc.): t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 White Birch Way IV."---I — Property Address Matthew White Owner Owner's Name information is West Barnstable MA 02668 January 21 2021 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 14"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: 10.5'x 5.5'x 5' 1500 gallons Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness <1" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle Under walkway How were dimensions determined? Dip tube and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place. Liquid level at outlet invert. Viewed with mirror. Outlet access under poured concrete walkway. Riser brings inlet cover within 4"of grade. Recommend maintenance pumping every two years with full time use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 White Birch Way Property Address Matthew White Owner Owner's Name information is required for every West Barnstable MA 02668 January 21, 2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of sc/to let tee or baffle Distance from bottom om of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 White Birch Way Property Address Matthew White Owner Owner's Name information is ry West Barnstable MA 02668 January 21 2021 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 floa switches, etc.): "Attach copy of current pu4ing contract(required). Is copy attached? ❑ 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.): One inlet, four outlets with speed levelers in place. 28" below grade. Light solids carryover. No high water staining over outlet inverts. Riser brings access cover within 6"of grade. t5insp.doc•rev.7/2612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 White Birch Way lv,V Property Address Matthew White Owner Owner's Name information is West Barnstable MA 02668 January 21 2021 required for every ry , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump c amber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 16 Infiltrator HiCap Units ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 9 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 White Birch Way Property Address Matthew White Owner Owner's Name information is West Barnstable MA 02668 January 21 2021 required for every ry 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.): 4 rows of 4 units. Vent is also inspection port. No standing liquid at time of inspection. Damp base. No staining in riser. No sign of past hydraulic failure. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater i low ElYes ElNo Comments (note conditio 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 4 Commonwealth of Massachusetts .UIR. . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 White Birch Way Property Address Matthew White Owner owner's Name information is West Barnstable MA 02668 January 21 2021 required for every ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, sig/fhydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doe•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 White Birch Way Property Address Matthew White Owner Owner's Name information is West Barnstable MA 02668 January 21 2021 required for every ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ` J J\ � r V 4a f-1 DEC `� f , / 3 O b 3 5 U 13 ' 3 << �� .Q t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 White Birch Way Property Address Matthew White Owner Owner's Name information is rY West Barnstable MA 02668 January 21 2021 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 Estimated depth to high ground water: >5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 2012 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: maps.massg is.state.ma.us/oliver.ph p You must describe how you established the high ground water elevation: Test hole in 2012 found no ground water at 11'. Base of units 6' below grade. Accessed local ground water contours and topo mapping. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/28/2018 Tide 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 t vt5 P-A, 48 White Birch Way Property Address Matthew White Owner Owner's Name information is West Barnstable MA 02668 January 21 2021 required for every ry page. Cityrrown 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 Commonwealth of Massachusetts A&-Qa-7- W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name % information is M re aired for every W Barnstable t✓ Ma 02668 5/25/16 4 page. City/Town State Zip Code Date of Inspection GD Inspection results must be submitted on this form. Inspection forms may not be altered in atny way. Please see completeness checklist at the end of the form. I� mportant:When � filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain r� Company Name 8 Johns path Company Address � S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation he Local Awrovina Authority 5/30/16 In ector's signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �oe l<S Commonwealth of Massachusetts , W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 White Birch Way Property Address ' John and Paulette Condon Owner.'.;;,,; Owner's Name informat7on is W Barnstable Ma 02668 5/25/16 requiredfor every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1500 GI septic tank as well as a concrete distribution box and 8 Infultrators. Field is 15x24x2 Installed in 1997 B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or'the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name information is required for every W Barnstable Ma 02668 5/25/16 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \a 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name information is required for every W Barnstable Ma 02668 5/25/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name information is required for every W Barnstable Ma 02668 5/25/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name information is required for every W Barnstable Ma 02668 5/25/16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name information is required for every W Barnstable Ma 02668 5/25/16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: System contains a 1500 GI septic tank as well as a concrete distribution box and 8 Infultrators. Field is 15x24x2 Installed in 1997 Number of current residents: 2 Does residence have a garbage grinder. El Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 187 gpd 9 ( Y 9 (gpd))-. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name required fo is ry W Barnstable required for.eve Ma 02668 5/25/16 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Last date-of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system El Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name information is required for every W Barnstable Ma 02668 5/25/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed 7/7/97 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Whit e Birc h Way Property p rty Address John and Paulette Condon Owner Owner's Name information is required for eve W Barnstable Ma 02668 5/25/1 every 6 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness Y Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1„ Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of leakin Tees and or baffles in place at time of inspection Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions.- Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CGM ,•y''p 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name information is required for every W Barnstable Ma 02668 5/25/16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are In place and levels are normal. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name information is required for every W Barnstable Ma 02668 5/25/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level and at normal level 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name information is required for every W Barnstable Ma 02668 5/25/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 15x24x2 8 Infultrators ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name information equir for is every W Barnstable required for eve Ma 02668 5/25/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No ponding no break out Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 6/9/2016 Assessing As-Built Cards TOWN OF BARNSTABLE LocATlox aq, 1AJvq SEWAGE# VILLAGE Ld.8grn ASSESSOR'S MAP&PARCEL /ag. 2' INSTALLER'S NAME&PHONE NO. 1341A Excavcv�i o�+ SEPTIC TANK CAPACITY LEACHING FACILITY:(type)2A r,r 46w4ors ell.) (size) y 25 NO.OF BEDROOMS 3 OWNER_ /�GrleSa�la. PERMIT DATE:—y-S-/Z COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(if any wetlands exist within i 300 feet of leaching facility) Feet FURNISHED BY AI'- 27' Az Z4 zz- 1'41 REAR As- 39' A4- ti9' Sy. http://www.townofbarnstable.us/Assessi ncJH M displ ay.asp?mappar=128027&seq=2 1/2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name information is required for every W Barnstable Ma 02668 5/25/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately 4 15ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name information is required for every W Barnstable Ma 02668 5/25/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/18/97 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: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 �R Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 White Birch Way Property Address John and Paulette Condon Owner Owner's Name information is required for every W Barnstable Ma 02668 5/25/16 page. Cityrrown State Zip Code .Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 FROM :down cape engineering inc FAX NO. :15083629880 Apr,. 19 2012 01:33PM P1 P1T?%� F41�:4.+11 1 R� F I6� `' ��� :_ 1I; }.��i)IIJ1��5 �ii'• RnGfl�4.fi� z'ag�'4:$elfi' BF3tMh'i'ntC.E. • `:,F�_asfi�_�-:�i ?'&�crrTaas l�'I1�.�c��n>I, •�}�n•a.a.d.�x' �Q.14> IA4f;�9i���7i�(� ,.�Q, u•tm eoi;i,1'6 k 0,760 01-licu: 08462 461,1 Fix: SQ$=19f} �S14 Date 3Cns:���rrcrr: �!,0+� r/1.�[vl •9�n�taabfl�u: �?L� C'.�(JGt.ny� ld (instttllra'} septic.,Sj'Rteru at vV I?1� �� rG� _WA�(q, bascd o:n a de-,.sign(1r,swa :-)y lboLt f1 f (� 5 dated — dusi _ T ct..rt,.&j that In, septic ,iysl ru xi:li;re.urec� ab(yve •eras iTotaJled subs,3iltially ac:cordiug to the dcsig, wlTieh mey include umicr Lq.ppfoved cInVigo:s suet. u Iatc:ra.l re.lccatinn ot-the cli�^tr..il-,utiun boz and/or septic tank.. T d:E;xtify that L'c1c7, SCp?iC 7-3rTteaaT. xc.ii�rvdr,i flove vv2L8 ilastzJed w:Lta ttuija ci',anges (i.e. -- ;7eaLftl f�jan.1.0' hiLt:ral relnuafion o_tl1r; SAS or any of,atdy ccmT)d!uL:nt Of 1r-1:1:t i1.L s.ccrmlancr wife Stat, & Local a cerLlilyd r14-hl11lj f y dP:iFer to tblio-w- KH OF DANIEL A. OJAiA (fn;�Lll till n`tta" �.� CIVIL fi No.46502 nh Fal 8 T�Q•���� w �SS10 N AL�NC� �r1L'7L�,1iF}'S St ;ilfltlT .) - ��tf'i�: �jrSl�II!'T' �ij:3lnp I.eT.s� f,?✓1eJ.Rld WP....B"J.°6;14,ULE••,_I'Ldtilf: FIT lrDIC1,410N.... L'E.R7CNTCATE (PF RIf9T ti1tJ'JtAi_,,Yk0'.l*-ff 'T'FrT€ ., ATU) kS4311Yf,9' BARD ARIE J���,��i'V�'l���T]if!•i��Ta.P��=i'�S}t;:d,:r,�1TJl(;9�L�_L�.la�..,:i.�1..Q•Pl�t��Ia�IV. 'A'?�A�7TC��te i. n- Cc7lificadoai:' rm 1-36-()4_d•7r. TOWN OF BARNSTABLE LOCATION )% G arcl iA]CLq SEWAGE# 901a• 08q VILLAGE ►d. Bart% ASSESSOR'S MAP&PARCEL I,;$• 2'? INSTALLER'S NAME&PHONE NO. 346 ExcavnA i o&j SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Xnfid w;Or$ (size) 11 y ms NO.OF BEDROOMS 3 OWNER e.rJC5e Aa. PERMIT DATE: . yS•/Z COMPLIANCE DATE: y•1'�•/Z 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 Al- Az- z.4' REAR 41 A3- 391 $ 83- L4 2' A4• 'q � w No. / 11�-� : Fee' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye 4phrAtion for Vspo'sAI Aksldu ConstCUCtlolt Permit Application for a Permit to Construct( ) Repair(✓) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 2 Vq h 1}e -31 rcAj�v Oar's Name,Address,and Tel.No. Assessor's Map/Parcel —," I2$--Pc+irGel 27 V3V� DO h n:,k1er keeencL 5 D 9-79 D -- 1 f 5 Installer's Name,Address,and Tel.No.SDg' 7 Q&15 3 D signer's NamWAddressand Tel.No. J,t0 3&2-4JLH Bi-a �XGavcawn i�-(i�tbe-�rYLn `f- LA �r- Q w Type of Building: Dwelling No.of Bedrooms Lot Size l a Sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3� gpd Design flow provided (��"/ gpd Plan Date "-I I�(12 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 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 o e th. 1 i S' ed Date �1 4 Application Approved by Date fLj Application Disapproved by Date for the following reasons Permit No. C901 r�)_ ox Date Issued �: :.•..--.-.,-.wr-_...� ....__-....:,,;.-�,�. ..: � ,_. . fir.. .-•...-, . .. _ .�.�. No. Fee 0� Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for MisposaY Op stint (Construction permit Application for a Permit to Construct( ) Repair(✓). Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. L 2 Vq h 1 t e 1 r'L.h Way O�tper's Name,Address,and Tel.No. JO h n_,A-Aer- CaEenCL 5 D94790 - 115 ( Assessor's Map/Parcel--ILA I 129 Po r-cet 27 tl)b Installer's Name,Address,and Tel.No. So k 7-Q 5 3 Designer's Name,Address,and Tel.No. r 9 3 9 ­A-1 5+ \ o h Type of Building: t Dwelling No.of Bedrooms J Lot Size h o/ �G.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures //ll p Design Flow(min.required)1 V gpd Design flow provided L 7 gpd Plan Date Ia`IZ Number of sheets ' Revision Date Title Size of Septic Tank Type of S.A.S. 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 o e Ith. S' ed Date (4' ` Application Approved by Date Application Disapproved by Date for the following reasons k Permit No. r901 _ Date Issued c THE-COMMONWEALTH OF MASSACHUSETTS .°`BARNSTABLE,MASSACHUSETTS - ��`� Certificate of Compliance f THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired 91 Upgraded( ) Abandoned( )by _ x LQ �,�i (o n at ' g h i r e 1 r(�(1 V has been constructed in accordance with the pgovisions of Title 5 and the for Disposal System Construction Permit No. 1� O y dated Installer r ( Designer- #bedrooms i3 Approved design flow 7j gpd The issuance of this permit sJha 1 not be 4onstrued as a guarantee that the system wjkl'fimc • i , ed. Date T 17 ) >, Inspecto N {� - - - Fee - - - o. _ ©� �zS THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS misposal �&pstrm Construction Vermit Permission is hereby granted to Construct( ) Repair(✓) Upgrade( ) Abandon( ) System located at 'j 1� I(C h C.( 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 becompleted within three years of the date of this permit. i Date �7 f f Approved by _ f o6' a Town ofBarnstable P,>r ret 1Depae'tlncnt of Regulatory Services Public He I alth Division Date 2— u BAAMBt'ABLE, 4 t" 200 Main Street, Hyannis MA 02601 PF0 Date Scheduled_ Tin-it Fee Pd. Soil Suitability Assessmlentfor S ,tic disposal Performed By: _ 1Ylhtessed By.: ' IL0 CA7[ION & G EN I RAJL INT4 O][8IVV1IATION Location Address LO w I.�c p 'dIty/ /�_ h) Owner's Name �P����P/✓l� I{r�`�AbI�L Address cc Aescssor's Map/Parcel: '120 1-7 Cngincer's Nautc (Iavd,—_ NEW CONSTRUM'lOPd REPALR Teleph011e fl Land Use e 6 ../�Q't:oti� Slopes(1/n) Surface Stones Distance's from: Opcn Water Body Ft Possible Wet.Arep ft Drinking Water Well 2®Oft Draiha.ge Way It Property Line Ft Other �s ft 6 SK E'7 CH, (Street name,dimensions of lot,exact locations of lest holes St perc tests,locate wetlunds'ln prmindty to I\oles) 37 15 Al I� d poaI- �►� r r- Vik '--r g' Parent material(geologic)_ �( Depth tp Rudroc �6G l� Depth to Groundwater: Standing Water in Hole: �U�4 Weepllig I'r0111 Pit Fttee 1. Estimated Seasonal High Oioundwater NJ yf q . .. D)CTERMI\TA7['IONr,OR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In, Depth to soil mottl58:. Depth to weeping from side ofobs-hole: e Ill. OrtluurJwuler At1f u9lrelent,r It, Index Well w Reading Date: y�rInldrnex�Well rlcvoll�l�r/h�TYr��AdjI,,+factor- Ati1,Ortwndwuter level Jl li�A'.0..�.YL �I JIK.l+.l s TES Observation Hole/1 Time tit V ZO Depot Of Per:; Start Pre-soak Time @ �0 _ Time(9"-6 End Prc-soak Sitc Su�tabllily Assessmunt: Site ha5sed_ Silg-Failed: Additional Testing Needed(Y/N) Original: Public hledlth Division Observation Hote,,Data To Be Completed on Back--- -- -- � 1"l`If percolation test is to be conducted Wltiiiin I®®' of vVefland, you must Ift-sit Uotaiy IORC. Barnstable Conservation Y)BVISIoI] it least one (1) Wech picior to begimflug. Q:\S EPTIC\l l:JKCPORM.DOC ID11C IP.O]C Sr][��TAi][][®107Tro—L { LOG _— Depth from Soil Iforizon ]Dole # Surface(in.) Soil Texture Sail Color (USDA). Soil• Other (Mansell) Moulin D g (Structure,Stones';Boulders, L Con istrary, a' ravel y/2 DEEP ®13S-E]f3VA'�'ION ROLE ]LOG Depth from Soil horizon Role le # (USDA) — Surface(in.) Soil Texture Soil Color Soil (Mansell) .. Mottling (Struclurcc,I er (M Stores, 13010de; Consis e c %Gravel tow DE E,P®BS.,RV�TTn�n���� ®� Depth from Soil Horizon 1101P,# Surface(in.} Soil Texture Soil Color (USDA) Sol l (MunsGll) Other Mottling (Structure,Stones,Boulders. Cousisteney 9a Onvell i DEq Ell1, op Sri Depth fi-om Soil H RVAT�ON HOLE LOG Ho rizon Soil Texture - Surfaca(in.) Soil Color 5011 (USDA) Other (Mansell) Mottling (Structure,Stones; Boulders, Cons' ten y gb pr X ——_- Lfggod Tingaurance Rate MaN Abnve 500 year flood boundary No Yes v ir✓ifhin 500 year boundary No_' y Yes Within 100 year flood boundary No� yp5 ID)e tip Hof Natulrflliy Occurring PYvious Material Does at least four fact 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 manorial? Cartii>fec�itaon _ A certify that on (' (date)I have passed the soil evaluator examination approved by the Department ofEnvironmet tal.firatection and that the above analysis was performed by me consistent with Ilse regoired training, expertise and experience descriUcd in 10 CAU2 15.017. Signature rr Da zy Z Q,\SSFTIC\PLRCFORM.DOC Form 4 -- System Pumping Record Commonwealth of Massachusetss Massachusetts M'4P .,. System Pumping Record PARCEL, , O 2., LOT System owner system Location Merlesena Deborah rental property 48 White Birch Way 54 Melbourne Rd West Barnstable, MA, 02660 Hyannis, MA, 02601 (508)-428-2345 x (508)-428-2345 x Type: Emergency - Routine Cesspool: No Yes Septic tank: w Yes Date of Pumping: 2L0 3 Quantity Pumped: IS Gallons System Pumped By: Wind River Environmental, LLC Permit#: Contents transferred to: Contends Disposed at: Date: I C " - 3 Pumper•Signature: C� Condition of System other Comments i pep Approved Form - 12/07/95 AsBuilt Page 1 of 1 - �f TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE nZ / //A//SSE R'S MAP& LOT INSTALLER'S NAME&PHONE N tt Dom` a� 4d -Ir 707 SEPTIC TANK CAPACITY Con__�V 1 LEACHING FACILITY: (type) (size) 1S pLc� NO.OF BEDROOMS 3 �A i BUILDER OR WNER T t d M<IerQk _ PERMIT DATE: 7 _1 - COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply WeU and Leaching Facility (If any weUs 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 fig` f I I r 831 a to 93- 3� http://issgl2/intranet/propdata/prebuilt.aspx?mappar=128027&seq=l 5/19/2011 ��/���db TOWN OF BARNSTABLE LOCATION �3� o� L )A k .L. 6-&"e SEWAGE # 91 VILLAGE 6,k J L--�, rro Q,4a6/ ASSE R'S MAP& LOT 1 INSTALLER'S NAME&PHONE NO. }✓(/U1'l1 r� ��Ke SEPTIC TANK CAPACITY /COO n� n LEACHING FACILITY: (type) t L� tc kthS (size) NO.OF BEDROOMS �� 3 BUILDER OR(OWNER] JDI dI �CSadk PERMTTDATE: '1 -'1 - 9`� COMPLIANCE DATE: ^2:�z 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 3 _ 83 93 3� I SfSTEM SHALL SYSTEM PROFILE AR ED WITHCMAGNETICTTAPE OR BE NOTES PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS APPROX. NGVD o��e ACCESS COVERS TO WITHIN 6" OF FIN. GRADE � PROVIDE INSPECTION FFRTSTO 2. MUNICIPAL WATER IS NOT AVAILABLE \ TOP FOUND. EL. 90.6' WITHIN 3" OF FINISH GRADE MINIMUM ,75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 92 �' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. MINIMUM JJOF COVER OVER PRECAST 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS TO BE AASHO H-M Church . 89. 4"OSCH40 PVC PIPES LEVEL 1ST 2' S. PIPE JOINTS TO BE MADE WATERTIGHT. Locu ' 10" EXISTING 14" , 88.2' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE TEE SEPTIC TANK** TEE 310 e g�t�h 8.4'f* 310 CMR 15.000 (TITLE V.) k GAS BAFFLE; °°°°°°°°°°°° 87.65' d ° f�c RETAIN D'BOX ooO�°C'°^O°O° ' &J Re 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND 88.0' 87.83' 92 86.73' OTHER PURPOSE.E USED FOR LOT LINE STAKING OR ANY 16 HIGH CAPACITY INFILTRATORS " 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. off' 6" MIN SUMP (NO STONE PROPOSED) ode err 12" MIN. INT. DIM. O.A. DIMS: 25' x. 11.3' x 0.92 DEEP 9. COMPONENTS NOT TO BE BACKFILLED OR �oa5 C oddief L011 6" CRUSHED STONE OR MECHANICAL o COMPACTION.SHED STONE 1 [2]) PROVIDE SPLASH PAD IF TOP-LOADING CONCEALED WITHOUT INSPECTION BY BOARD OF S MIN. MIN HEALTH AND PERMISSION OBTAINED FROM BOARD ( 1 R SLOPE) ( 1 % SLOPE) 4.73' 46't OF HEALTH. EXIST. EXIST. PROP. 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP FOUNDATION EXIST. SEPTIC TANK EXIST D' BOX 14' LEACHING D' BOX 20' CALLING DIGSAFE (1-888-344-7233) AND NOT TO SCALE FACILITY VERIFYING THE LOCATION OF ALL UNDERGROUND & **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE BOTTOM TH 1 EL. 82' WORK. ASSESSORS MAP 128 PARCEL 27 UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM CONDITIONS IF NOT SUITABLE G-W AT APPROX. EL. 40 PER TOWN MAP SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILI*SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE ??s�, SAND. IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR BY HEALTH INSPECTOR IT � �77.71 SYSTEM DESIGN. PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED Ews� / BY THE BOARD OF HEALTH REVISED DURING A PUBLIC 78.70 GARBAGE DISPOSER IS NOT ALLOWED HEARING HELD ON AUG. 4, 2009 /80.15 DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD 3) FAILED SYSTEMS ONLY : SOIL ABSORPTION SYSTEM - INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW ��' USE A 330 GPD DESIGN FLOW GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) O i� .eo�a -�W.1 eo.o4 AND WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS `�' �� SEPTIC TANK: 330 GPD (2) = 660 BE LOCATED MORE THAN SIX FEET BELOW GRADE. f3.48 /r81.73 RE-USE EXISTING SEPTIC TANK" X83.26 �45 80 � LEACHING: .../ 44.45 y ' %� 4.73 SF/LF x 6.25' LENGTH = 29.56 SF PER HIGH CAPACITY INFILTRATOR UNIT 8597 N 330 GPD/0.74 GPD/SF = 445.9 SF, LEACHING \ \ � REQ'D TEST HOLE LOGS ■ \ N \\ /�/ 88.73 �i / C 445.9 SF/29.56 SF/UNIT = 15.1 UNITS , /87.90 . ENGINEER: ARNE H. OJALA, PE, SE \ ,'� PAVED DRIVE i THEREFORE, USE GRAVELLESS SYSTEM OF (16) ' H-20 HIGH CAPACITY UNITS IN FIELD WITNESS: DON DESMARAIS, RS o 92 ��'0.S068 i /i CONFIGURATION OF 4 ROWS OF 4 UNITS DATE: MARCH 29, 2012 PROP. VENT WITH CHARCOAL FILTER < 5 MIN INCH AND BUGSCREEN (FINAL PLACEMENT BY \ _/9° 9� 16 UNITS x 29.5 SF = 472 SF > 445.9 SF PERC. RATE = CONTRACTOR WITH HOMEOWNER °' 90 �� 06 /�� ,,� 472 SF (0.74) = 349 GPD (OK) 13589 CONSULTATION) 3�.,90. Q CLASS I SOILS P# 92. 6 �2� 0 ELEV. ELEV. `1 N 09 2 O„ 4 92' O" 4 92' : S LOT 2 �`.� , MA A A 53 0.94 DECK 44,179 s.f. APPROVED DATE BOARD OF HEALTH LS LS 69 1 10YR 2/1 6" 10YR 2/1 41� 7 5 TITLE 5 SITE PLAN B B EXIST. DWELL. I �P OF LS LS 9�09 „ 10YR 6/6 „ 10YR 6/6 \ z,43 7 0� PpRON 9t 91.11 9 / ��� 48 WHITE BIRCH WAY 36. 89.0 . 36 89.0 .o6CR� po 7 / ��, WEST BARNSTABLE � ,6 BE H MARK - POOL CON 1.17 ` r RO HERE EL - 91.1 "o?Oak- AP \ ^ \ •91 91.1 r PREPARED FOR C C \ .25 C�91.91 •� PERC 9 91 �`a�LZNOFt�gss9cys� ����(NOFMgs B&B EXCAVATION/ \92.73DANIELA. ° DANIEL 0) MERLESENA / 9 00 <� OJALA N MS MS Q 95.26 \ 1ry U �. 0 A �D No.46502 - 0980 yo 193.96 �° ���� - p p p APRIL 2, 2012 Op 10YR 7 4 10YR 7 4 `"\ �'� � / / \ off 508-362-4541 EXISTii SYSTEM SH PER s c1% -362-9880a+ VE THE TOWN DANIELA. ti ° DANIEL P�w'� A. downcope.com OJALA ALA CIVIL NO40 EO ? down cope en /neer/n /nC. 120" 82' 120" 82' � � • 502 ,\ .,l �. 8 �l F G,STE� , �N'' civil engineers NO GROUNDWATER ENCOUNTERED Scale: l = 30 ' ,_ _ aver _ land Surveyors I 939 Main Street ( R to 6A) 2-O 62 0 15 30 45 61 75 FEET ATE DANIEL A. OJALA, P.E., .L.S. YARMOUTHPORT MA 02675