HomeMy WebLinkAbout0020 ACRE HILL ROAD - Health y/
20 Acre ll ll.Road
Barnstable
298-111 -
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Commonwealth of Massachusetts
W Title 5 Official Inspection Fgrm
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
20 Acre Hill Road, Barnstable MA 02630 I6'a
Property Address �Q
Thomas Connaughton w° I
Owner Owner's Name
information is 60 Arbor Way, Hyannis MA 02601 August 8 2008
required for -
every page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted.on this form: Inspection forms may not be altered in any
way.
i Important:
When filling out A. General Information _
forms on the
computer,use 1. inspector: - r, C- Cda
only the tab key r>
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.' 77
Company Name c
rea 189 Cammett Road
Company Address
Marstons Mills MA 02648
renrn Cityrrown State . Zip Code
508-428-1779 SI 12855
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(raining 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 by the Local A proving Authority
August 8, 2008 ,
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board .
of Health or DEP)within 30 days of completing this inspection. If the system 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 DER 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.
08-211 Connaughlon.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
r Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Acre Hill Road, Barnstable MA 02630
Property Address --- —
Thomas Connaughton
Owner Owner's Name
? information is.
required for 60 Arbor Way, Hyannis MA _ 02601 August 8, 2008
every page. City/Town State Zip Code Date of Inspection
-y
B. Certification (coot.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
t
'i 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:
Tank is not in need of pumping at this time, distribution box was replaced for inspection
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 El.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.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructedpipe(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
08-211 Connaughlon.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
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Commonwealth of Massachusetts:
4 Title 5 Official Ins ection Form
p
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
•'r 20 Acre Hill Road, Barnstable MA 02630
Property Address -
a Thomas Connaughton
7 Owner Owner's Name
I information is required for 60 Arbor Way, Hyannis MA 02601 August 8, 2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont:)
B) System Conditionally Passes (cont.):
;j ❑ distribution box is leveled or replaced
ND Explain:
1
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❑ 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
❑ obstruction is removed
ND Explain:
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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 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 tank and SAS and the SAS is within 50 feet of a private water
supply well.
08-211 Connaughlon.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Acre Hill Road, Barnstable MA 02630
Property Address — -
Thomas Connaughton
Owner Owner's Name
information is 60 Arbor Way, Hyannis MA 02601 August 8, 2008
required for y y -- — g
every page. City/Town State Zip Code Date of Inspection
B. Certification(coat.)
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C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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 forma
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3. Other:
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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
.11 or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
than_day flow
Required pumping more than A times.in the last year NOT due to-clogged or
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obstructed pipe(s).Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
E ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a,surface water supply.
08-211 Connaughlon.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form:-.Not for Voluntary Assessments
�M 20 Acre Hill Road, Barnstable MA 02630
Property Address --------
Thomas Connaughton X
Owner Owner's Name
information is 60 Arbor W Hyannis MA _02601 ' Au ust 8, 2008
required for ayy, _
' every page. City[Town State Zip Code Date of Inspection
i
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes_ No
/
❑ M 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.
❑ MAny 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
El ® 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.mustserve a facility with a
design flow of 10,000 god to 15,000 god:
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
El ❑ Area-IWPA) or a mapped Zone li 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 0 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.'
08-211 Connaughton.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Acre Hill Road, Barnstable MA 02630
{ Property Address
Thomas Connaughton
Owner Owner's Name
information is Y; Y 60 Arbor Wa Hyannis MA. 02601 Au ust.8, 2008
required for __. g ..
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
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❑ ® Were any of the system components pumped out in the previous two weeks?
i ❑ . ® 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?
® El Were as built plans of the system obtained and.examined? (If they were not
available.note as N/A)
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a ❑ Was the facility or dwelling,inspected for signs of sewage backup?
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® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?.
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® ❑ 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
El information on the pro per,maintenance of subsurface sewage disposal systems?
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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) [31.0 CMR 15,302(5)]
08-211.Connaughton.doc 08/O6 Title 5 Official Ins
pection ection Form Subsurface
rface Sewage Disposal System•Page 6.of 15
Commonwealth of Massachusetts
u Title 5 Official. Inspection Form:
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Acre.Hill Road, Barnstable MA 02630
Property Address — --
Thomas Connaughton
Owner Owner's Name -- -------- :
information is
required for 60 Arbor Way, Hyannis MA 02601 August 8, 2008
Cit drown State Zip code Da
te of Inspection
eve page. Y P P
fY P 9
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D. System Information
i Residential Flow Conditions:
Number of bedrooms (design): 3 -- Number of bedrooms (actual): ?
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DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents. 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes .separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No.:
Seasonal use?. ❑ -Yes No
Water meter readin s, if available last 2 -ears usage d 5000 gal.
9 ( Y 9 (gp ))�
Sump pump? ❑ Yes ® .No
Three years prior
Last date of occupancy:
' to inspection.
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:
Last date of occupancy/use:: ` Date
Other(describe): ---- -------- —--- —
OB-211 Connaughlon.doc•08/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
i Title 5 Official Inspection Form
{
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Acre Hill Road, Barnstable MA 02630
j Property Address
I Thomas Connaughton
+' Owner
i Owner's Name
information is
required for 60 Arbor Way, Hyannis MA 02601 _ August 8,2008 _
every page: CitylTown State Zip Code Date of Inspection
:I
i .
D. System Information (cont.)
General Information
Pumping Records:
! Source of information: Tank pumped 7/14/05
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Was system.'pumped as part of the inspection? ❑ Yes. ® No
If yes, volume pumped:
gallons .
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i How was quantity pumped determined? - ---
Reason for pumping: — —
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
.Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a,copy of the current operation and
maintenance contract (to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1979
Were sewage odors detected when arriving at the site? ❑ Yes ® No
08-211 Connaughton.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�o�^* 20 Acre Hill Road, Barnstable MA 02630
Property Address — ---- -----
Thomas Connaughton__
j Owner Owner's Name ------ -- —
I information is
required for y, y g 60 Arbor Wa Hyannis MA 02601 August 8 2008
every page. City/Town State Zip Code Date of Inspection
j
D. System Information (cont.)
Building Sewer (locate on site plan):
Depth.below grade: 2'
feet
Material of construction:.
1 ❑ 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):
2 .
Depth below grade. feet
Mat
erial ial 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) El Yes ❑ No
Dimensions: 8.5' long x 5.2'wide- 1000 gala
Sludge depth: 2".
Distance from top of sludge to bottom of outlet tee or baffle 28
Scum thickness Trace.
6„ .
Distance from top of scum to top of outlet tee or baffle --
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Measured
08-211 Connaughton.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments
.'y 20 Acre Hill Road, Barnstable MA 02630
Property Address -- ---- -
'Thomas Connaughton j
owner Owner's Name
information is 60 Arbor y g
required for.. bor Wa Hyannis MA 02601 August 8, 2008
every page. City(rown 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 ofieakage, etc.):`
Tank is not in need of pumping at this time, tees were,found intact and clear.
Grease Trap (locate,on site plan).
Depth below grade: feet
Material of construction: .
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness ;
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels.as related to outlet invert,evidence of leakage, etc.):
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 ❑ ex
( p other lain
)9 08-211 Connaughlon.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
{ a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Acre Hill Road, Barnstable MA 02630
�I
Property Address
1 Thomas Connaughton .
I Owner Owner's Name
j information is 60 Arbor Way, H Hyannis MA 02601 August 8, 2008_
.required for y g
Cit /Town . State ''Zip Code Date,of inspection
' every page. Y - .. P P
` D. System.Information (cont)
Tight or Holding Tank (cont.)
Dimensions: ---
i
Capacity:
j gallons
Design Flow:
i gallons per day
I .. Alarm present: ❑ Yes ❑ No
Alarm level:. Alarm in,vvorking order: [I Yes ❑ No
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Date of last pumping:
Date
I Comments (condition of alarm and float switches, etc.):
I
Attach copy.of current pumping contract (required). Is copy attached? ❑ Yes: ❑ No
Distribution Box (if present must be opened) (locate on site plan):
0"
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage:into or out of box, etc.):
D-box is new, was replaced for inspection.
. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order-, ❑ Yes ❑ No
08-211 Connaughton.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11:of 15
Commonwealth of Massachusetts
f s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Acre Hill Road, Barnstable MA 02630:
i
Property Address
Thomas Connaughton
Owner Owner's Name
information is 60 Arbor Wa H annis _ _ _MA 02601 August 8, 2008
required for ��_ g
every page. City/Town State Zip Code Date of Inspection
.
D. System Information cons.
j
I Comments (note condition of,pump chamber, condition of pumps and appurtenances, etc.):
i
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Soil Absorption.System (SAS) (locate on site plan, excavation not required):'
If SAS not located, explain why:
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Type
® leaching-pits number:
One 6x6 pit.
II .
❑ leaching chambers number.
❑ leaching galleries number: .
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❑ leaching trenches number; length:
i .. -
❑ leaching fields number,.dimensions:
Ej overflow cesspool number:.
❑ innovative/alternative system
Type/name of technology: —
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Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching pit was found empty at time of inspection with a high stain line at 75% capacity.
{
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08-211 Connaughton.cloc•08106 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 15
i Commonwealth of Massachusetts
Title 5 Official Inspection Form
i s Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
20 Acre Hill Road, Barnstable MA 02630
` Property Address
Thomas Connaughton
Owner Owner's Name
information is 60 Arbor Way,N Hyannis MA 02601 August 8 2008
required for y g ,
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
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
Dirriensions of cesspool
Materials of.construction
- Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs.of hydraulic failure, level of ponding; condition of vegetation,
etc.):; :.
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Privy (locate on site plan):
Materials of construction`.
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I -
i
08-211 Connaughton.doc.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
20 Acre Hill Road Barnstable MA 02630
Property Address
Thomas Connaughton
Owner
---
. .Owner's Name
information is 60 Arbor Way, H Hyannis - MA 02601 Au ust 8, 2008
required for - .- -- ...-_. ... - _._.... - - �- — -- -- --- --
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System:. Provide a sketch of the sewage disposal system including ties
to at least two permanent reference iandrnarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.;
I .
49 3T
21
Slider w.
24,
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Water
Service
Driveway
Acre Hill Road
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Acre Hill Road, Barnstable MA 02630 .
Property Address
Thomas Connaughton
Owner Owner's Name --
ration isrequied for 60 Arbor Way, Hyannis MA 02601 August 8, 2008
every 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 ground water; More than 30 feet.
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: pate
❑ 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:
UEGS topo map and town GIS.
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You must describe how you established the high ground water elevation:
1 Town groundwater contour map shows water below el. 25 and topo map shows property at el. 100.
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08-211 Connaughlon.doc•08/06 Title 5 Official inspection Form:Subsurface Sewage Disposal System Page 15 of 15
Town of Barnstable
�p THE Tp�
P
Regulatory Services
g Y
' Y Thomas F. Geiler,Director
BARNSTABLE,
.y MASS. �O
1639. a Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number
of bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIC\Disclaimer Private Septic Inspections.DOC'
TOWN OF ARNSTABLE
LOCATION ���� r �l SEWAGE# S�
VILLAGE r(\s7e,b ASSESSOR'S MAP&PARCEL
INSIT*E-L- 'S NAME&PHONE NO. �'f�'C. p� f ® I
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) r (size) 060
NO.OF BED OOMS 3
OWNER.
PERMIT DATE: CO -M*W-,.FE DATE:9-,ASP (
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
49 37
21
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24
waver _ II
Service Driveway
;::
t Acre Hill Road
No. 6 „d J Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V
` PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
pplicatiou for Dig 0 Y �pgtem �tComstruction per it
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑.Complete System Individual Components
Location Address or Lot No.4:4® Cam/I Owner's Name,Address,and Tel.No.
`4'7
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. ~� Designer's Name,Address and Tel.No
yr� .
ry��J�dr �'
3-)6- 10 t• 51)l //
Type of Building:
Dwelling No.of Bedrooms Lot Size Al sq. ft. Garbage Grinder ( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) / gpd Design flow provided gpd
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)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. Q
Signed Date
Application Approved by Date p 6 -L
Application Disapproved by: Date
for the following reasons O
Permit No. ;®6 3 1 Date Issued 0 g
'6 -a
—————————————————————————————————————
TSFTTS
Feeh�o—
''' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC
B _ Yes
U LIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS
(ppgication for TDi9;Po#a1 *pgtem Congtruction Per ml it r
Application for a Permit to Construct Repair(Upgrade( ) Abandon( ) ❑.Complete System 0 Individual Components
Location Address or Lot No.,, Cp/t h�v, h '`o✓
Owner's Name,Address,and Tel.No.
# Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. ✓ � n � Designer's Name,Address and Tel.No.
�/fT�rl cj)
Type of Building: /
Dwelling No.of Bedrooms ! � Lot Size/y �''�YT sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) [�!� gpd Design flow provided gpd
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)
Date last inspected:
.Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. q
-Signed Date
( ! LL
Application Approved by .� 7/ Date L '
Application Disapproved by: Date
for the following reasons
Permit No. ;-0 6 b — 3;�01 Date Issued /!rG -0
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (✓) Upgraded ( )
Abandoned( /5f,/)by r/4// A �., I)nX
at car (� r-w„ V/ in, i/ vwA�Irj4i has been constructed in accordance �/
with the p-rovisions of Title 5 and the for Disposal System Construction Permit No. . Do� — 3201 dated -6-5
Installer 3 11�1 1,jl Designer AI II-)
#bedrooms J I,Q Approved desiign�flowr\ r/t/r gpd
The issuance of this permit i;hali not be construed as a guarantee that the system willl functiion,as designed. f
Date I () n Inspector t - /Iq,/ Z.c) 45
No. 2-dOg— 391 _ Fee /00 -
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
ai.gpo!6a1 ,p!5tem Co 55 gtruction Permit
Permission is hereby granted to, Construct, ( ) Repair (t/ Upgrade ( ) Abandon ( )
System located at /7/I �� � �,..41;j l sle
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 thispetmi
Date g V�of Approved by
TOWN OF BARNSTABLE
0
LOCATION /,21 2c} �oi ���� �� SEWAGE #
VILLAGE U� �i1y-► % j�/Z ASSESSOR'S MAP & LOT a tt I
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY 160-6
LEACHING FACILITY:(type) (size) Inn ;p
NO. OF BEDROOMS- PRIVATE WELL O UBL�I� W�A�E '
BUILDER OR OWNER�'1 Q6151-1.1__7)A-
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: d V &�,y 0-U/Jvticg
1
VARIANCE GRANTED: Yes No
T
G?c � � Hid. al (7D
� ►
L0.eATwO SEWAGE PERMIT NO.
VILLAGE
INST LLER' NAM rADDRESS
8 U I l D E R OR (� OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED ��/��
sLIwo
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliratinn -for Diiipuoa1 Workii Tonotrnrtinn Prrutit
Application is hereby`made for a Permit to Construct l ) or Repair ( ) an Individual Sewage Disposal
System at:
F-------- ---------- ---------a.0...---.............................................
Location-Address or Lot No.
jp�MF_`$..... Ent.......................................... .............. LE-----..............................................
Owner Address
------0E'I a2Iw...`�.os,------------_---_------_ `�QI,�ST .e.---
Installer Address
Type of Building Size Lot.4_1_5_ O------Sq. feet
., Dwelling—No. of Bedrooms-------3--------------------------------Expansion Attic WO) Garbage Grinder (Wo
aOther—Type of Building -_JU./�•1............. No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures j2oam---------------------------------------------------- ---------------------------------------
Design Flow___..__...IZO........................gallons per �i per day. Total daily flow____....._.J..�.0....................gallons.
WW _ _ _ _ r s0 r iY r YY
Septic Tank—Liquid capacitvJ®AP-gallons Length_,�__.�_._... Width_. __1,0..._.. Diameter---------------- Depth---Zk---Q-... '
x Disposal Trench—No.---_--__---__--___ Widtli-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No....../__-_-___-__- Diameter.....$........... Depth below mkt--
6__ ._.__ Total leaching area..aa0_Q_sq. ft.
z Other Distribution box ( a� Dosing tank ( ) O �` ���
aPercolation Test Results Performed by._RQfa A.cZ>._..*1....Gt!GEPA,0�_ ...R.S...__ Date---M%Y._.Sf1��$..
Test Pit No. 1__G--9-.-_minutes per inch Depth of "Pest Pit____________________ Depth to ground water_______-.---.--_-
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
---------------------------•--------------•---------
Description of Soil-------- > ...----.Z-61_94V...-A.��------ [1T3..S_Qi'G.----------------------------------------------------- ---------------=-------
v .......... .A_41__2?-----------------------------------------------------------
W . ------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
F U•:,• Nature of Repairs or Alterations—Answer when applicable.-----------------_.-----_-__-------_._.-..--.--_--____-.--.-.-_.-.....-.--_.__---___-._--.._..
---------------------------------------------•----------------------_-------.----------•----------•------••-•-•--------------•-----•-•--••-•-•------ ------•-•-...................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
igne -------••----••-•-•-•--------------------------------••-----•-
v Date
Application Approved By----- �c rs --------------------- •--- -- �/-`7k.
Date
Application.Disapproved for the following reasons----------------- ------ -------------------------------------------------------------------------------------
. •--•-...--•---------•-•-----------••---•-••----•••-••••-----••-
-----------------------------------------------------------------------
-----------------------
Date
_ a
Permit No....................................•.................... Issued.-----��.._..�-------_-7. -----------------•--=•---
Date
JK
THE COMMONWEALTH OF MASSACHUSETTS
5-::;.K.• BOARD OF HEALTH
.... ........_OF....... ..!9.1�.J4j S..;�"�..L�.�..;�'................................•.
Appliration -f it Uhip al Workii Towitrurtion Mani t
Application is hereby'made for a Permit to Construct (V ) or Repair ( ) an Individual Sewage Disposal
System at:
Location--Address. or Lot No.
.. `+.......................................... ....�K.lhk .l c--------•---•---•--•--------•--•--------•------------
Owner Address
Installer Address
Q Type of Building Size Lot.4..5.80......Sq. feet
U Dwelling—No. of Bedrooms.____:-. ------ - --------------------Expansion Attic WO) Garbage Grinder (tits
0 p-1 Other—Type of Building --J%). ..............1�� No. of persons--------- ------------------ Showers ( ) — Cafeteria ( )
Qa Other fixtures ---------------------'•----- - --.-------------•-•---
•-•---------------------------•--------------------------------------------
W Design Flow---_______f10........... ...........gallons per, p`r day. Total daily flow..........�.3.8_..._........... ._ .gallons.
Wi Septic Tank—Liquid capacity-/900-gallons Length_, _+ n_. Width.4't4.'... Diameter--------- ------
x Disposal Trench—No..................... Width-------------------- Total Length_._-___-_--__.-_--. Total leaching area....................sq. ft.
Seepage Pit No'.____/__-__--_---- Diameter.._., ..°�...... Depth below in t_ i Total leaching •trea..a_0-Q_sq. ft.
z r Other Distribution box ( � Dosing tank ( ) Ohl* l " `
aPercolation Test Results Performed by.. p64kD----4....4:51.A-Mb....X.S--___ Date---/-VAX----
Test Pit No. 1_ ...a---minutes per inch Depth of Test Pit.................... Depth to ground water.--.---._.--.--.-.-----
IX4 ,Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to,, ground water-----------------------
-------------------------------------------------------------------- .
DDescription of Soil_----.0--!t.. --` ----------- --,04.0....�ti/� �t1�1J3--�c2�'�: -------------------------------------------------
m;"� " - '��------ tl. ---------.5 911 -D---------------------------- ---------------------------------
W
l_U Nature of Repairs or Alterations—Answer when applicable...............r-------------------------------------------------------------I------ ............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued L.
by the board of health.
igne = •-•-•-•--•-------- ----------- ------ ------------------------
D
Application Approved BY ;-- --------------
Date
Application Disapproved for the following reasons:........................ ----•---------------------------•----• .......................................
..................................•.......•------•------------_-••----•----------•-•••-•-----•-••-•-........__......----••------------ --------------------------- -------------------------------------
Date
PermitNo. '-••--•-••••••------------••--•--•-•------... Issued-------------------------------`=------=-----•-..------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
M1 f.
(Irrtif rate of f111ntpitat rr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
b .......... � t-�=�-----1.!�ZON---------------------------
L. 'Waller
at.............................-•----?___0. C t`ILL.-•- �t-��' Aik n"lf•?�11�E...S. .
has:been installed in accordance with the provisions of . XI of The State Sanitary Code as described in the
application P -'9-
a hcation for Disposal Works Construction Permit No. • ✓S',�'_______________. dated..... ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............. --------•----------................. -Inspector--- ---....-
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
" w ........... . .................................... ,
No........... ......-•-••-
%nVviial Workii Qlaintitrurtion Prrmit
Permission ' ereby granted.....01 !P!4tw......
to Construct.(✓ ) or Repair ( ) an Indiv' ual Sewage Disposal System
at No.10T-----10
-•---•--- ckkt... t i'L----- 41;tee.......................... ..': _
Street
as shown on the application for Disposal Works Construction Per . No Dated----- -7k .-
,.T --
oard� fHealt
DATE........ 7._ -----------------------------------------
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�EDTic TANK L�/57-.2/BUT/ON 80X
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p �yJ
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i/'v11L G.e� `► �°' 1 ,U,?/VEWAY VOT_ TO BE ,LOCATED
� �F
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x,: r r ,,._ _,,,``a•.'T7E.S/Gi\! L 0�1 D/�/G !S USED.
S N ERE13 Y C ERT t r Y ;HAT THE EXI.S T/N c7r
FO, UNtAT/ON LOCATION /:5 C0R,R ECT AS
5�1 �fN AND rr DOES �N' F'u R "WITH
THE L3U1LC?/,,ifs SEA t t?CK " � C U1 M47/,j7"S l FaaS7��E`®
OF TX 7' rWN fAR.NT1# O
DATE 41E,AL77/ Ai T