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Home My WebLink About0009 GROUSE LANE - Health - -- 9 Grouse Lane Hyannis .F/R j A = 268 .252 - 6 I ti G atoll-aka-- Commonwealth of Massachusetts Title 5 Official Inspection Form P Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M -268 P-252 Property Address Barry Johnson Owner Owner's Name information is required for every 165 Concord Lane, Cisterville MA 02655 January 12, 2021 f 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, use only the tab Troy Williams key to move your Name of Inspector cursor-do not Troy Williams Septic Inspections use the return Company Name key. 19 Hummel Drive � Company Address South Dennis MA 02660 City/Town State Zip Code (508) 385- 1300 S1682 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 January 20, 2021 Inspector's Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Iz� Title 5 Official Inspection Form iia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M -268 P-252 Property Address Barry Johnson Owner Owner's Name information is 165 Concord Lane Osterville MA 02655 January 12, 2021 required for every � ry page. Citylrown 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'P,asses: ® 1 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 meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. 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," explain. lain. P P 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 I Commonwealth of Massachusetts ,p Title 5 Official Inspection Form �1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M -268 P -252 Property Address Barry Johnson Owner Owner's Name information is 165 Concord Lane, Osterville MA 02655 January 12, 2021 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 14*1 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M 268 P-252 Property Address Barry Johnson Owner Owner's Name information is 165 Concord Lane, Osterville MA 02655 January 12, 2021 required for every ry 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M -268 P-252 Property Address Barry Johnson Owner Owner's Name information is required for every 165 Concord Lane, Osterville MA 02655 January 12, 2021 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z 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 15,000 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f 9 Grouse Lane, West Hyannisport M -268 P-252 Property Address Barry Johnson Owner Owners Name information is 165 Concord Lane Osterville MA 02655 January 12, 2021 required for every ry page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes'to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was tl-e 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 tie 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: Existin information. F r® ❑ g o example, a plan at the Board of Health. Determined in the field if an of the failure criteria related to P( y art C is at issue ® ❑ approx mation of distance is unacceptable) [310 CMR 15.302(5)] l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I c Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l 9 Grouse Lane, West Hyannisport M -268 P -252 Property Address Barry Johnson Owner Owner's Name information is required for every 165 Concord Lane, Osterville MA 02655 January 12, 2021 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: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: N/A 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 20=48,000 gals. g ( y g (gpd))' 19=51,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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 11. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M -268 P-252 Property Address Barry Johnson Owner Owner's Name information is 165 Concord Lane Osterville MA 02655 January 12 2021 required for every � ry , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow (based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: N/A Industrial waste holdingtank resent? P ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A Last date of occupancy/use: N/A Date Other(describe below): N/A 3. Pumping Records: Source of information: Last pumped on 1/5/21 per info from owner. 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 �r Title 5 Official Inspection Form 1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M -268 P-252 Property Address Barry Johnson Owner Owner's Name information is required for every 165 Concord Lane, Osterville MA 02655 January 12, 2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System.: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: D-box and leaching were installed to existing tank on 12/23/02 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18"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.): Lines were found clear at the time of inspection. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts r p Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M -268 P -252 Property Address Barry Johnson Owner Owner's Name information is 165 Concord Lane, Osterville MA 02655 January 12, 2021 required for every ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 2' With riser to 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: 5'X9'X6' 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 2' 8" Scum thickness none Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? probe/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.): Inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form ISubsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M -268 P-252 Property Address Barry Johnson Owner Owner's Name information is required for every 165 Concord Lane, Osterville MA 02655 January 12, 2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (lo--ate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A 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.): N/A 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Capacity: N/A p ry' gallons Design Flow: N/A gallons per day t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 AAI Commonwealth of Massachusetts p Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M -268 P-252 Property Address Barry Johnson Owner Owner's Name information is 165 Concord Lane Osterville MA 02655 January 12, 2021 required for every � ry 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: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): D-box was found level and in working order. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M -268 P -252 Property Address Barry Johnson Owner Owner's Name information is required for every 165 Concord Lane, Cisterville MA 02655 January 12, 2021 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A * 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: 2 -500 gallon with stone ❑ leaching galleries number: 24'X 12.5'X 2' ❑ 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 Commonwealth of Massachusetts ,9 Title 5 Official Inspection Form 'i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M -268 P-252 Property Address Barry Johnson Owner Owner's Name information is 165 Concord Lane, Osterville MA 02655 January 12 2021 required for every rY page. CitylTown 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.): Soil was sandy. Chambers had a low water level present at the time of inspection. Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A 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 < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M -268 P-252 Property Address Barry Johnson Owner Owner's Name information is 165 Concord Lane, Osterville MA 02655 January 12, 2021 required for every _ ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5insp.doc•rev.7/2 512 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth monwealth of Massachusetts ig Title 5 Official Inspection Form F' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Grouse Lane, West Hyannisport M -268 P-252 Property Address Barry Johnson Owner Owner's Name information is 165 Concord Lane Osterville required for every _ _ MA 02655 January 12, 2021 page. Cit own 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 �y r 5s ' �1 t5insp.doo•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 II c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 9 Grouse Lane, West Hyannisport M -268 P -252 Property Address Barry Johnson Owner Owner's Name information is required for every 165 Concord Lane, Osterville MA 02655 January 12, 2021 page. Cityrrown 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: 15.0'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If cl-ecked, date of design plan reviewed: 11/2/02 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Chucked with local excavators, installers- (attach documentation) ® ,Accessed USGS database -explain: MIW 29 Zone C 9.1' 4.5' adjustment You must describe how you established the high ground water elevation: Test hole recorced on plan showed no water found at 11.1'. Groundwater adjustment at the time of inspection was 4.5'. Bottom of leaching at 5.5'was found not to be located in the high groundwater elevation at the time of inspection. 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 9 Grouse Lane, West Hyannisport M -268 P-252 Property Address Barry Johnson Owner Owner's Name information is 165 Concord Lane Osterville MA 02655 January 12 2021 required for every � ry , 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. Q 00a-531 Fee 5 0 0 0 D THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes �- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Wood Opotem Conotruction Permit Application for a Permit to Construct( )Repair(x)o upgrade( )Abandon( ) D Complete System f�_]Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 9 Grouse ln. , i Hyannis Dan Morin Assessor's Ma /Parcel y 'i rM-252 �n�'r ,q c� Insraller'SWm:'' Ssi<odbi'noson Septic servic �Sigt'e�avi aCougriTanowr P.O. Box 1089 43 Triangle Cir Centerville., MA 02632 Sandwich , MA 09561 Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Buildingresidential No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date 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) we will install a new Title-5 1 _a c-h system to the plans of David Coughanowr #ETE-1305 dated 11 /5/02 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 Bo r f Health./ Signed�� 1.� Date Application Approved by Date Application Disapproved for the following reasons Permit No. ao®a - S3 7 Date Issued ��—13 —O 3 No. a ooa- 5 31 Fee 50.00 j THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer: - •� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS ZIpprication for �Digoga[ bpotem Construction Permit Application for a Permit to Construct( . )Repair(x4 Upgrade( )Abandon( ) O Complete System 0 Individual Components Location Address or Lot No. 9 Grouse l n. , Owner's Name,Address and Tel.No. Assessor'sMap/Parcel Hyannis Dan Morin 268-252 Susan Installer's e,Address Tel.No. Designe.5�'s N e,,pd ss and Tel.No. w "m'. c;. °o inson Septic Servic llaV Goughanowr v P.O. Box 1089 43 Triangle Cir Centervil6e, MA 0263 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Buildingresldential No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow t gallons per day. Calculated daily flow gallons. Plan Date 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) we will install a new Titte-5 leach system totthe plans 66 David Coughanowr #ETE-1305 dated 11 /5/02 Date last inspected: Agreement: ' r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo f Health.J� Signed _1-1- Date Application Approved by Date Application Disapproved for the following reasons Permit No. adOa - 5-3 9 ; ' Date Issued .3 Morin THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (x))Upgraded( ) Abandoned( )by Wm. E. Robineen Septic Service at 9 Grouse Ln. , Hyannisport has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No o2=-5, `I dated Installer William E. Robineen Sr. Designer David Couchanowr The issuance of this permit shall not be construed as a guarantee that the sy to will unction `s�des,,igned. Date 1 a �� Inspector / It\ �5. v No. 9009—5-3 Fee $5 0.00 Morin THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS 1wi6posaf *pgtem Construction Permit Permission is hereby grant d to Construct )Repair( x�Upgrade( )Abandon( ) System located at Grouse n. , Hyannisport and as described in the above Application for.Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: 1 1`/.3 _0 0L Approved by, 'J�w,--Q �• "! V TOWN OF BARNSTABLE LOvt►TiON ? si L• �^ SEWAGE # (`i � G� Jr� VILLAG a °= i 14'AA'ISSESSOR'S MAP & LOT ,26�'�S� INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ,'�- �'1 (size) i�)- NO.OF BEDROOMS�3�� BUILDER OR OWNERG PERMIT DATE: 3 CAL 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 300 feet of leaching facility) Feet Furnished by I! - - "/ � � ^:.�' 1---�-,._._ l �� :� 'Y� _-- �� L � �� C�� y ;, �� S , , f TOWN OF BARNSTABLE LOCATION -� ��. SEWAGE VELLAG �o= �'n"�ISSESSOR'S MAP & LOT ' - fn INSTALLS 'S NAME&PHONE N0. C�� `� ' SEPTIC TANK CAZ11ITY 16''''� LEACHING FACEL : (type) '�--/- 6 (size) /2 "a`Jr- NO.-OF BEDROOMS BUILDER OR OWNER /Vc, , ! J'" PERMITDATE: /� .3`"C1 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 Feet within 300 feet of leaching facility) Furnished by 007 6 l M -z— i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y i ti yt V� 4 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A &PECT10N Property Address: 9 GROUSE LANE WEST HYANNISPORT,MA 02672 Owner's Name: MORIN Owner's Address: 9 GROUSE LANE WEST HYANNISPORT,MA 02672 rkAv Date of Inspection: 11/20/00Name of Inspector: (please print) JOHN GRACIpGCompany Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 .i E Telephone Number: 508-564-6813,FAX 508-564-7270 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 the inspection.The inspection was performed based on my training and g 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 _ Needs Furt Evaluation by the Local Approving Authority X Fails Inspector's Signature: d Date: 11/20/00 The system inspector shall submit 1copy 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 appraving authority. Notes and Comments THE SYSTEM FAILS TITLE VINSPECTION.THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING, AT THE TIME OF THE INSPECTION THE PIT WAS FULL TO THE PIPE. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection i does not address how the system will perform in the future under the same or different conditions of use. Y L., i Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 GROUSE LANE.W,EST HYANNISPORT,MA 02672 Owner: MORIN Date of Inspection: 11/20/00 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Secticer 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: THE SYSTEM FAILS TITLE V INSPECTION.THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING,AT THE TIME OF THE INSPECTION THE PIT WAS FULL TO THE PIPE. 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. Answer yes,no or not determined(Y,N,ND)in the for the following statem:;nts. If"not determined"please explain. n/a 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 anal if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a 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 _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more jhan 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 _obstruction.is removed 4 ND explain: n/a 7 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 GROUSE LANE WEST HYANNISPORT,MA 02672 Owner: MORIN Date of Inspection: 11/20/00 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: 1�• _ 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 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 tankiand 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to jhis form. 3. Other: n/a r Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 GROUSE LANE WEST HYANNISPORT,MA 02672 Owner: MORIN Date of Inspection: 11/20/00 D. System Failure Criteria applicable to.all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/2 day flow X Required pumping more,than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n1a. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or'privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool dr privy is within a Zone I of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 col iform bacteria and volatile organic compounds indicates that the well is free from pollution from that facJlity 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.] X _ (Yes/No)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. You must indicate either"yes"or"no"to each,of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet,of a tributary to a surface drinking water supply _ X 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 airy 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. n i Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9 GROUSE LANE WEST HYANNISPORT,MA 02672 Owner: MORIN Date of Inspection: 11/20/00 Check if the following have been done.You'must indicate"yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were riot available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? X _ 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? X _ Was the facility owner(and,occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems'? 7! The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ 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(3)(b)] t L} r f Page.6 of 11 C OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9 GROUSE LANE WEST HYANNISPORT,MA 02672 Owner: MORIN Date of Inspection: 11/20/00 FLOW CONDITIONS 5. RESIDENTIAL 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 Number of current residents: 4 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a E COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15,:203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no):NO Non-sanitary waste discharged to`th..-Title 5 system(yes or no): NO Water meter readings,if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: n/agallons --How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soi� absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,A,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) ' Tight tank Attach a copy of the{DEP approval , Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1971 Were sewage odors detected when arriving at the site(yes or no): NO i f <i Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 GROUSE LANE WEST HYANNISPORT,MA 02672 Owner: MORIN Date of Inspection: 11/20/00 BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:24" Material of construction:Xconcrete metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8'6"H 5' 7" W 4!40"" Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle: 22" Scum thickness: 14" " 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: n/a 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.): THE SYSTEM FAILS,THE LEACH PITS ARE PAST THE EFFECTIVE DEPTH OF LEACHING.PROPER MAINTENANCE FOR SEPTIC SYSTEM IS TO PUMP EVERY TWO YEARS. GREASE TRAP:_(locate on site,plan) - 5 Depth below grade: n/a �•4'i Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc;¢; n/a {is 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 GROUSE LANE WEST HYANNISPORT,MA 02672 Owner: MORIN Date of Inspection: 11/20/00 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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 DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenanes,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 GROUSE LANE WEST HYANNISPORT,MA 02672 Owner: MORIN Date of Inspection: 11/20/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6'X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system ,Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE SYSTEM FAILS TITLE V INSPECTION.THE LEACH PIT IS FULL UP TO PIPE,THE PIT HAS NO EFFECTIVE LEACHING LEFT.THE SYSTEM FAILS CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no):NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a ' Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 GROUSE LANE WEST HYANNISPORT,MA 02672 Owner: MORIN Date of Inspection: 11/20/00 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. E b(A Q . o n G A4)6L A 9 34, Ic 51 EzA34L Na i 4 in f Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 GROUSE LANE WEST HYANNISPORT,MA 02672 Owner: MORIN Date of Inspection: 11/20/00 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12 +feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavafors, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET h ii 11 I V Commonwealth of Massachusetts r� Executive Office of Environmental Affairs De artment of , MAY 2 7 1997 '" Environmental Protection William F.Weld Gowmor Trudy Coxe Sscrelary,EOEA n David B. Struhs l7 Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: C-3rr; SL t Address of Owner: Date of Inspection: ]-ap--7-? (If different) / Name of Inspector; ��e , �=66 Company Name, Ad ess and`Telep one umber: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported belov,, 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: V Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signat un AFL Date: '.� The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. li 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 appropria!e regional office of the Department of Environmental Protection- The-original should be sen: to :n,e >vslem owner an(i copies sent to the buyer, if applicable and the appro,.inn a,;.,orlty. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I 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 septiCCi Jhk-is metal;cracked, 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 conforming septic tank as approved by the Board of Health. (revised e/15/95) One Winter Street 0 Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 iJ Printed on Recycled Paper 62 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A -'CERTIFICATION (continued) Property Address Owner: �� •`.` / Date of Inspection: is c7 �� 7 B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, 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 than four 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 obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: �7 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 DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECI THE PUBLIC HEALTH AND SAFOY 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH'JAND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE EIXIRONME\T: _ the wsten-i has a septic tanK anu suii �bsurpliuii System and is within 103 fi=6 10 a sui41Cc naici �Lipplr o. trlbuiar) tci a surface eater supply. _ em and is within the system ha a septic tank and soil absorption syst , thin_a Zone I of c a.publi water supply well. _ The system has a septic tank and.soil absorption system and is within well. 50 feet of a private water supply _ The system iias 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• D] 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 cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: (�twc r Owner: 6-c, Date of Inspection: -15-b-a-t 17 D] SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. L Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. .L/ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. d 'Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: 1 he following ctilcvia apply to large systems in addition to the cntena above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following 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 8/15/95) 3 0 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B• CHECKLIST Property Address: ct, Owner: Cry. Date of Inspection.. Check if the following have been done: v//Pumping information was requested of the owner, occupant, and Board of Health. V None 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 pan 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. _ he system does not receive non-sanitary.or industrial .waste flow _/fhe site was inspected for signs of breakout. 4II 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 existing information or a xrmated by nun-intrusive"methods. _T he ;;J• '' o.c jpants, if difle�o Lon, ovrner! were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised s/i5/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Cj Owner: Co(-(-04 Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:__ajU_gallons Number of bedrooms: Number of current residents: t� Garbage grinder (yes or no): Iq Laundry connected to system (yes or no):4— Seasonal use (yes or no):/� 1 1. .. - 1 ... - Water meter readings, if available: Last date of occupancy: 6U• C:1 ,7 COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ .Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: �) /L,rU y System pumped as part of inspection: (yes or no)_ If yes, volume pornpr d. gallons Reason for pumping: TYPE-O"YSTEM _._.__ ._.-...,..._.. '✓ 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: ✓S i Sewage odors detected when arriving at the site: (yes or no)/? (revised 8/15/95), 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: c't �,;�,�� G c • �� &wti-4 Owner:6>'I�/ `� jL Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below grade: , --- -Material of construction ,concrete,__,metal _FRP _,other(explain) Dimensions: Sludge depth: ai' Distance from top of,sludge to bottom of outlet tee or baffle: 7 Scum thickness: _ p of outlet tee or baffle: Distance from top of scum to to Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: condition of inlet and outlet tees or baffles, depth of ligt�*d level �y elation to outlet invert, structural (recommendation for pumping, integrity, evidence of leakage, etc.) GREASE TRAP:L\ (locate on site plan) Depth below grade: ---Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance frorn bottom hntlnrr o1 PUi1P! 'Pe 0� hatlle' Comments: dd conion of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural (recommendation for pumping, integrity, evidence of leakage, etc.) 6 (revised 6/=5/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �>t[iLSiiT'�1-•�tti+�_ ♦�-(��w:�y`��t p 1 Owner: 6OeFe-/ Date of Inspection: -DO 7 TIGHT OR HOLDING TANK:-,&-/ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain). . Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: -Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan! Depth of liquid level above outlet invert: Comments: (note ii levei anti drstribu)wi, > euua:, e--dcnce of so!.d> ca,r)o,er, evidence of leakage into or out of box, etc.) PUMP CHAMBER _d (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 6/15/9s) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: �-�' �.�.•,,( Date of Inspection:6_�,",7 SOIL ABSORPTION SYSTEM (SAS): not re wired, but may be approximated by non-intrusive methods) (locate on site plan, if possible; excavationq If not determined to be present, explain: - Type: leaching pits, number: . leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: _ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) t y t!eL L�i •a�_ CESSPOOLS: (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 groundwatc:. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, sighs of hydraulic failure, level,of ponding, condition of vegetation, etc.) --- PRIVY: (locate on site plan) Dimensions: Materials of construction: Depth of solids:__ ion of soil, si Comments: (note conditns of hydraulic failure, level of ponding, condition of vegetation, etc.) 8 (revised s/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: GU(%�•T 7 Date of Inspection:. SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' o � 3 DEPTH TO GROUNDWATER Depth to groundwater: l J feet _ method of determination or approximation: l ') ` �. (-a ' (' r;, mob e�'t z•✓ 4�Nif (revised 6/15/95) 9 TOWN OF BARNSTABLE LOC":�TION S ,40 y Se I- Al SEWAGE # VILLAGE f/yA&AIIS ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY / 6� LEACHING FACILITY:(type) PO/T (size) %,p d NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No (�� ', _, �� \ �� • �,� ,, � e , - � I'/ d O v\ t''� .� .�. � �s �4 .,,...e :t i� � a cc�� ► c2D $ 3 0.0 0 ¢f I Fx$.............................. BernstaDf6 CUf1SBfV3t10n D@p8rtf1�61T E COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q WN OF BARNSTABLE S' ed Date Appliration for Diri.pooul Worltg Togt6trnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair XX)i an Individual Sewage Disposal System at: „9 Grouse Lane West Hyannisport ..... ..... .....- ---•• --•------------•---•----•------••-----•--...--•-••---•....._...•---------------------------------- Location-Address or Lot No. Coffeyy._.......................................................................... 0,ner .Address W J.P.Macomber Jr . ...............................................---•-•--•----•-••••-------------•----•-------••---- -.................. --•-•---•---........--•--•--------•-•-------•-------.....----.......--•- Installer Address VType of Building Size Lot............................Sq. feet ,.� Dwelling—XNo. of Bedrooms._.........._3_________________-_-.-_-_Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures --------------------------------- - Design Flow............................................gallons per person per day. Total daily flow.................................._.........gallons. W 0L Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GT4 Test Pit No. 2................minutes per inch Depth of Test Pit----................ Depth to ground water........................ a -----------------------------------------........................... _...._.............---......... ...... .........--........•-------- ._........ ......-•--...- 0 Description of Soil.............................................ad.rid...Fx...az_a el.---------------------------------------------------••----••----•------...---.... V .....--•-----••--------------•••----•••--------•-----•---••-----------------`--••-•-----------------------------•------------------------•-------...........--•---•--•-----------------•----••--••------- W ••-•----•--------------------------•------•••...••----------------------------------.-•------------------------- x Giriit two cesspools . Install U Nature of Repairs or Alterations—Answer when applicable................................................................................................ .1.-.1.000---gaLi-on.... ank...1.- is_tx.ihlzi;.i.axt--- a ---J-DODD---cQFa.1.I oJ.1...leach...pi.t.......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee iss ed by the board of hea.th. Si ned ........ .. 8/27/93 g ... .... .......... ..............-�_e................. A hcation A roved B ................................. ..��:�.../�.-.. . PP PP y ................. ,�- Application Disapproved for the following reasons: ................... . ................................................................................................ --- ............................................ .................... ... ................ .. ............................................... ........................ ............. Permit No. ------- Issued Dare NO.....-�-` 1 f l Fide$........0. THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH S ,.-- -3TOWN OF BARNSTABLE s,l Appi iration for Di►ipniul Wurbi Towitrnrtinn ramit Appll ation is hereby made for a Permit to Construct ( ) or Repair �XY) an Individual Sewage Disposal System,at: 9 Grouse. Lane••_West_.Hyannissort ........................ -•----------------.._....-------•----•----.....-•-------•--•----•----------------....---•....•--• . 11 Lorition-Address or Lot No. Cof feX------••-••••-----------••-••-----••••----------------------•----- Owner Address a J.P.Macomber Jr. ------•-•...................•- --.........--•---•----•-••......-----------------•-••-......---- ............................................. ----............................................... Installer Address Type of Building Size Lot............................Sq. feet Dwelling- No. of Bedrooms______________3----------------------_-----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 04 Other fixtures ------------------------------- - - Q -- ------------------------- ------------------------------- •------......------.. 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. 3 SeepagetPit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Resultsl Performed by.......................................................................... Date........................................ Test Pit No. I........'._._.__minutes per inch Depth of Test Pit.................... Depth to ground water........................ LZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------------------------------------------------------------------------------------------- --------------- ............................ . O Description of Soil--------=----------------------•--------•...sa d--•.&-ax'ayal--------------------------•-----...-------------•--._...-•••••......••--.............. x x Omit hwo cesspoois.Y,...Install...... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... _. ally t a?ik -d . .tr.i.but.2 Qt1... o c. 1-:1.000._.gallon leach...pit-' Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the _ system in operation until a Certificate of Compliance has bee issued by the board of heaYth. � 8/27/93 Signed ..... 7.;....� 1� ... '1...... ...t-... . .. . _...........pie................. Application Approved B t�� . /.......,....-..----fe:a�.. Pp PP Y .................... . �.-.. f P Dace Application Disapproved for the following reasons: ..................................... ...._............................_ .......... ............................... ............ . ........................ ........... ... . ...........................--... ..................................... .1.........--............. ............ Date Permit No. ------- --4 . ........... Issued ...................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�ertiftrate of CZomplinure THIS IS TO CERTIFY, That the Individual Sewage Disposal System em constructed ( ) or Repaired (XXX)C by J.P.Macomber Jr. ....................... ...........-.............-...-......... ...... ......}-----------.------.--------------.------------------------------ ............................. ......... 9 Grouse Lane West Hyannisport m,tauet at ................ ......_.......--....... ..........._.....--..--....---..---------- -----.. ------------------...----------------------------------.---------------------------...-..----.-.-----. has been installed in accordance with the provisions of TITLE 5 of The/State Environmental Code as described in the application for Disposal Works Construction Permit No. ......_G.7-.y........... .fated ..-_........... ....._............. ..-.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. l DATE.................. ...i.... 1 _....--.. Inspector ----......................... �-_ .(- -. `� \ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH q TOWN OF BARNSTABLE .. 3 0.0.. FEE. ... ... 11isposal Nab Tunntrurtinn '"rrmit J P.Macomber Jr. Permissionis hereby granted----- -'_...--•-------•-----------••••--••----•-------------------------•------•---•-----------------------•-----••---.....--•............. to Construct ( ) or Repair N�l ag Individual oSrytage Disposal System 9 Grouse Lane Y p - _ at No Street qq � as shown on the application for Disposal Works Construction Permit No._\/5-4;? -Y— Dated......�'�:.. -..�r°._3....... ----------------------------------------- C IIoard of Health DATE.. i!.•---.--.......�--1..................................... FORM 36308 HOBBS&WARREN.INC..PUBLISHERS t OF-B--RNSTABLE--.--` LOCATION U SEWAGE # 9 _ VILLAGE—4-fi n'�:(— uy l ASSESSOR'S—MA-P--&-LOT INSTALLER'S NAME & PHONE NO.J ,l,^�Ll C- 4 SEPTIC-TANK-CAP ACI-TY-- _— - - ----- — ---- ---- _.- NO. OF BEDROOMS —PRIVATE ,WELL OR PUBLIC WATERvv DATE PERMIT ISSUED: DATE—C-O-M-PL-IA=NGE-ISSU=E.D: ..— VARIANCE GRANTED: Yes No �� 1 Cz 2� t ASSESSORS MAP NO: : .� PARCEL NO: �,:, $ 3 0.0 0 No... FnB.......................... APPROVED THE COMMONWEALTH OF MASSACHUSETTS A�,04&,,not"C,,nservalionD",o"s BOARD OF HEALTH 30-T TOWN OF BARNSTABLE Application is hereby made for a Permit to Construct ( ) or Repair X an Individual Sewage Disposal System at: q 12 Shorey Road Hyannis West Hvannisport ) - .. - ........... Coffey Location-Address or Lot No. ......................—.......................................................................... .......................•-•----••----...---•--••----...-••--•-••--••............................... Owner Address a J.P.Macomber Jr. -•--•-•... ........ Installer Address UType of Buildin_f 3 Size Lot............................Sq. feet t-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—T e of Building No. of persons............................ Showers — Cafeteria 0.' Other 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........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ 14 Test Pit No. 2................minutes per inch Depth of.Test Pit---................. Depth to ground water........................ S-a fd---&---Grra-ce l----------------------•--......------------------•------------•---.....-----------•----•-------•---•----•-----•---.--•-- ODescription of Soil....................................................................................................................................................................... W .. .. U ......-•---••-•-------------------------•-------•-•--•-------------------------------•---------------.....---••---------------•---•------•---------------•.-----•-•-•-------------•-•-••...-------------- w ---------------------------------------------------------------------------------------------------------------------------------------------------------------........................................ U Nature of fSp -,sor "'atf 8pS re-a sa ve giv en applicable. -------------•--------------- --------------•-...------•-•-----------•----•----------------------------......---------------...-----------------•--................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia e has b en�•ssued by the b and f health. Signed �° E.�.19 ..2-............ Date ApplicationApproved By ------------------- ------ . . ----.. --------------------------------------------------------------- .... Application Disapproved for the o lowing reasons- ------------------------------------------------------------------------------------------------------- .......................... ------------------------------------ .----........--------------........................ --------.........-- -----....-- --- -- .-- --------.....................................------------ .. -------------------...---...... Date PermitNo. ------- e ...�.. ,.��Q....................... Issued ..................................... -------------------------- Date � 30-00 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF BARNSTABLE Application is hereby made for a Permit to Construct'( ) or Repair (XX)'�an Individual Sewage Disposal Location-Address or Lot No. Installer Address Pq . feet '' - ' -��Jo c� �tt� ( ) �r��r ( ) Other—Typeof Building ............................ No. of persons............................ Showers ( ) -- Cafeteria ( ) Otherfixtures ---.--_----.-'-'--------_---------.._---------_-------..______________ Design Flow............................................gu)ouo per person per day. Total daily flow............................................ . Septic Tank—Liquidcapacity............gallons Length_............. Width................ Diameter------ Depth................ Disposal Trench--No .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit 2Jo.-------. Dianoetor.----.--.. Depth below inlet.................... Total leaching area.....L.----'sq. b. Z Other Distribution box ( ) Dosing tank ( ) - '- Percolation Test Results Pwrfooucdbv--_------------------------------. Date........................................ Test P6 No. L------minutes per inch Depth of Test Pit-----.......... Depth to ground water.------'_. rX� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth toground water........................ - � ' ��d-7G''\��T---'---'--------------'--'--'-----------------'---------- �� Deucr�ti000fSoJ........................................................................................................................................................................ -----'-'-`---`-`-------`--------------'-------`----`------`--------`---`---------`-------'' _ --.---------'-_----..---_-_.------_---__---'_-------'___-I.-_'--_.-------_'-'__--.. [] Nature of �� -.-------_ ------- ai on leac pi � -'------.��-�'�'��_��'-��.�.�-��'��_'--____-'--'_'_-_-'-------'-..--..-----.---_____. /�grcemeoz: The undersigned uQcecy to install the ufoze6cocrdbcd Individual Disposal System io accordance with the provisions of TITLE 5 of the Srurc Eoricouozcunul Code--The undersigned budzer agrees not to place the | system in operationl a Certificateof Compliance b beddb, Signed �� ` 2------------ Date Application Approved By Date ApplicationDia for the o lowing c1lowiisons: ---__---__-----_-_------__-_-_-_' -- ------- ^� Ptzouu �Jo- --'��'m�'�-��'�'*�-------' loxoe6 ---------------------..... Date � THE COMMONWEALTH OF MASsAC*ussrrs � BOARD OF HEALTH TOWN OF BARNSTABU E �� =°°~~^~~ra~~ +^^ `L10+=y^,=~^ce 4 � THIS IS TO CE877Fl| That the Individual Sewage Disposal System constructed ( ) or Repaired ( XX�) �� - -, --��`�]�v08��`��'��"------------------------------------------------------------- � West B��DlO��*"�' at --]��-|S)�C\rgy--�Il ga---------------------c------------------------------------------' has been installed io accordance with the provisions uf TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. --' duceJ ---------------- OF ISSUANCE � THUS CERTIFICATE SHALL NOT B _PE�,NSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIOSATISFACTORY. DATE '�~ / ~�- lcm��cnn� �� `� \ ------.~--'~-----------------------' " ------------------------ THE ooMMomvvEALrx or wAsSAoHussrrs BOARD OF HEALTH N OF BARNSTABU E FEE� ~ ' FLOW PROF-ILE TOP OF FOUNDATION RAISE COVERS TO WITHIN rEL - 38.87 6 in OF FINAL GRADE ZZASN /n_ X 2" LAYER OF 1/8" �3' DROP f v BO 1/2 0 m STONE FLOW LINE _ 3/4"-I I/4" lO - 14' STONE PRECAST �"' �' 48- G,A.S DRYWELL 0 \ BAFFLE 34J5 6 in BOTTOM OF L STONE 33.55 LEACHING SYSTEM SOL SORPTION EXISTING BASE �G EXISTING 37 GALLERY 33.30 5.00 f I + 1000 GALLON (END VIEW) 3L30 rav SEPTIC TANK 32.5 rl e) 13.7 fr 12.5 fr 61 4.5 fr V _ ESTIMATED SEASONAL HIGH �/ NM01 GROVNDWATER (IV (7-706�� Z �x mlAHw3Avd o m y 1=. m C5 cn oo O� � 3J03 A m y _{ O y O m >y—rim Z =Z � x �� ' � I zq To r —1 69 12 p m no 0 C) y� r �1 I _ GI m V QE3Add o A"03 6/ riPD r z � O � I C M o � m� NV� o o I w �m� m �� mz r•`� f, < Z m cn D p Dy-h one :oC° Z mm �o 3Z0 =m vi7� m 3Z m 300 y zv NNy M m oo 7C7 D v,rn fTT �v -V N� Z ® 1 12.5 fr Z Z� to n �Z to m ° 3 � O Z3m � Z X Rl y 0 rr Z y i x G) Z rn G�Ql a , 0 e Z ' C W 0 x ;U m -p m c0 v> oo N � CJ7 c>>N -a 1v m m \ J G) (/) �9 Y O O mo c � cn m \ o G) m m mm m O m n Z < o Nz6n < CD n = Y m mos4-cn v, z 3 m o w W m m - X \4 A r z go p � 00 _ > Z � �om n m o moNyy�`� Z 0 m ' IQ -< z Y� O p �LS in a>� o° O z o cn < ,.row -,. y c6 fT, � cfl n Z z rn � —� f, W o —v o i �MfTof3Tl U� r 3 - �,�9�0 may n v m m D Z 7U Z _� Sl l�s�� r Z o Z m p'—� z G) p• m o v 0 Z a=1 N (NIT Cq ~ � a, m y Z Z SOIL TEST L O G DATE OF TEST: NOVEMBER 2. 2002 s SOIL EVALUATOR: DAVID D. COUGHANOWR. RS DESIGN CALCULATIONS WITNESS REQUIREMENT WAIVED NO GROUNDWATER TEST PIT I PARENT MATERIAL: E ROG ACIALDOUTWASH DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD ELEVATION - 38.10 +- PERC AT 46 in : 2 MIN/INCH IN C SOILS SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER ONCHES) HORIZON TEXTURE (MUNSELL) MOTTLING USE EXISTING 1000 GALLON SEPTIC TANK IF IS SOUND STRUCTURAL CONDITION. IF NOT, INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) 0-6 FILL 6-7 O LOAM 10 YR 2/1 NONE FRIABLE DISTRIBUTION BOX: USE 3 OUTLET D-BOX. 7-8 E LOAMY SAND IO YR 3/2 NONE FRIABLE SOIL ABSORB.TION SYSTEM: A 24 ft x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH 8-10 A LOAMY SAND 10 YR 3/4 NONE FRIABLE A b o t - ( 24 x 12.5 ) - 300 s 10-38 B LOAMY SAND 10 YR 4/4 NONE LOOSE A s d w - ( 24 - 24 12.5 - 12.5 ) x 2 - 146 s f 38-134 C MED-CS SAND 25 Y 6/3 NONE LOOSE-5i STONES Atot - 446 sf Vt 0.74 x 446 - 330.04 GPD USE A 24 ft x 12.5 ft x 2 ft GALLERY. Vt - 330.04 GPD > 330 GPD REQUIRED GROUNDWATER ADJUSTMENT OBSERVED OW: 15.0 LEACHING GALLERY BARNSTABLE GIS RECORDS INDEX WELL: MIW-29 CONSTRUCTION DETAIL ZONE: C READING: OCT 2002 YWELL UNIT STONE LEVEL' 9.9 8'-6'x 4'-10'x 2'-Q' ADJUSTMENT: 5.6 ft 2 f+ EFF. DEPTH T � ADJUSTED GW: 20.6 \ 24.0 ft N OIE o 1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN N 7 N 2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES 2.5' 8.5' 2 ft 8.5' 2.5' BEFORE EXCAVATING FOR SYSTEM, 24.0 ft NOT TO 5) EXISTING LEACH PIT TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED 7SCALE 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE 7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0' BEFORE PITCHING DOWN .8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK 9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. SEWAGE DISPOSAL SYSTEM PLAN 10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. 11) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL -TO SERVE EXISTING DWELLING STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH SUSAN M. ANDERSON SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING 1 2) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED 9 GROUSE LANE HYANNISPORT. MA . FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. ECO-TECH ENVIRONMENTAL 43 TRIANGLE CIRCLE SANDWICH MA 02563 ETE-1305 I NOV 7. 2002 2/2