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HomeMy WebLinkAbout0071 DORAL ROAD - Health 71 Doral Ave Barnstable A= 349 - 033 _ ° y n Commonwealth of Massachusetts Title 5 Official Inspection Form"J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Doral Road Assessor's Map 349 Parcel 33 Property Address Charles W. and Mable J. Holmes Owner Owner's Name ' information is Barnstable/Cummaguid MA 02637 Aril 30 2014 required for every P � ` 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. Please see completeness checklist at the end of the.form. . Important:When filling out forms A. General Information _ • `. on the computer, use only the tab 1. Inspector: I (� key to move your1� cursor-do not David D. Coughanowr, RS' use the return Name of Inspector key. w Eco-Tech Rapid Response rab Company Name P.O. Box 1265 , - Company Address. West Chatham MA 02669 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification certify that I have personally in the sewage disposal system at this address and that the information reported below is true,.accurate and complete as of the-time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance'of on site sewage disposal systems. l am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: �ytA OF K Passes, y> ❑ Conditionally Passes ❑ 'Fails DAVID yes El Needsdie Local Approving'Authority's �O� AFt a No.1328 1 a April 30, 2014 Inspector's Signature ` Date Thesystem inspector shall submit a copy of this inspection report to he Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form: ace Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts j W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Doral Road Assessor's Map 349 Parcel 33 Property Address Charles W. and Mable J. Holmes Owner Owner's Name information is required for every Barnstable/Cummaguid MA 02637 April 30, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. 4;&A The septic tank is metal and over 20 years old*or the tbp4, tank�(Wh�ether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltratiore.or tabKf6ilure4svimminent. System will pass inspection if the existing tank is replaced with a cpmjlyingasetptl �tanats approved by the Board of Health. (" ` *A metal septic tank will pass inspection if it is structut/ally sound;,not'leaking and if a Certificate of Compliance indicating that the tank is less than 20 yearbsod ' variable. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessmerrts M 71 Doral Road Assessor's Map 349 Parcel 33 Property Address Charles W. and Mable J. Holmes Owner Owner's Name information is Barnstable/Cumma uid MA '02637 Aril 30, 2014 required for every q p page. Cityrrown State Zip Code Date of Inspection ' B. Certification (cone.) { ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): I ❑ 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 - ,E], ND (Explain below): ❑ obstruction'is removed ❑ Y ❑ N .0 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 k .❑ Y- ❑ N, ❑ ND (Explain below): ❑ obstruction is removed Y ❑ Y ❑ N ❑ ND (Explain below): �t a .-C Further Evaluation is Re uired b the Board of Health: a y ❑ 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 ma Panner which wilf protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland orb salt marsh f t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Doral Road Assessor's Map 349 Parcel 33 Property Address Charles W. and Mable J. Holmes Owner Owner's Name information is Barnstable/Cumma uid MA 02637 Aril 30 2014 required for every q p page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within*a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: Y pp Y You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool - El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less q than /z day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal'System Form - Not for Voluntary Assessments �M 71 Doral Road Assessor's Map 349 Parcel 33 Property Address Charles W. and Mable J. Holmes Owner Owner's Name information is Barnstable/Cummaquid MA 02637 Aril 30 2014 required for every p page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within.100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is'within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or pr'ivy.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: , 0 E] The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes or"no"to each of the following, in,addition to the questions in Section D: Yes No ❑ ❑ the system is within 400 feet of a'surface drinking water supply ❑ ❑ the system is within 200.feet of a tributary to a surface drinking water supply El Eli the system is located in a nitrogen.sensitive area (Interim Wellhead Protection Area=IWPA) or a mapped Zone.[[ of a public water supply.well If you have answered "yes"to any question in Section E7the'system is considered a significant threat,or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . c,M s 71 Doral Road Assessor's Map 349 Parcel 33 Property Address Charles W. and Mable J. Holmes Owner Owner's Name information is required for every Barnstable/Cummaquid MA 02637 April 30, 2014 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 9pd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts ` Title 5 Official Inspection Form.• Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 71 Doral Road Assessor's Map 349 Parcel 33 Property Address Charles W. and Mable J. Holmes } Owner Owner's Name information is Barnstable/Cumma uid �b. MA 02637 Aril 30 2014' required for every q p page. City/Town +State Zip Code, Date of Inspection D. System Information Description: System was installed by Larry Ellis in 1987 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in,this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 104 gpd 9 ( Y 9 (gpd)): i Detail: 2012: 27,000 gallons 2013: 11,000.gallons' Sump pump? ❑ Yes No . ago Last date of occupancy:Y 18mnh months 9 - Date Commercial/Industrial Flow Conditions:' . Type of Establishment: , Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,.etc.): - Grease trap present? ❑ Yes ❑ 'No- Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 I Commonwealth of Massachusetts W Title 5 official Inspection Form l; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Doral Road Assessor's Map 349 Parcel 33 M µ Property Address Charles W. and Mable J. Holmes Owner Owner's Name information is Barnstable/Cumma uid MA 02637 Aril 30 2014 required for every q p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner's agent Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 V I - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Doral Road Assessor's Map,349 Parcel 33 Property Address Charles W. and Mable J. Holmes ' Owner Owner's Name - information is Barnstable/Cumma uid MA 02637 Aril 30 2014 required for every G p page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of.information: 27+ years. Certificate of Compliance for new system issued,1/7/1987 (Permit#86-680) Were sewage odors detected when arriving at the site? , ❑ Yes ® No Building Sewer(locate on site plan): " - 2 Depth below grade: - P 9 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwellin Septic Tank(locate on site plan): j Depth below grade: - T 0.5 feet Material of construction: Z`concrete ❑ metal ❑ fiberglass ❑ polyethylene [],other(explain) If tank is metal, list age years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 x 5 x 6-1000 gallon Sludge depth: 8 in l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Doral Road Assessor's Map 349 Parcel 33 Property Address Charles W. and Mable J. Holmes Owner Owner's Name information is Barnstable/Cumma uid MA 02637 Aril 30, 2014 required for every q p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 26 in Scum thickness 0 in Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is not required at this time. Maintenance pumping is recommended within 2 years and every 2-4 years thereafter with year round occupation. Tank and tees appear structurally sound and functioning as intended. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass.. ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form - Not for Vol untary'Assessments �M 71 Doral Road Assessor's Map 349 Parcel 33 3. Property Address Charles W. and Mable J. Holmes Owner Owner's Name information is Barnstable/Cumma uid MA 02637 Aril 30 2014 :. required for every q p page. City/Town 'State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): f Tight or Holding Tank(tank must bepumped at tim e of inspection) (locate on site plan): , Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): _f Dimensions: Capacity: .` gallons Design Flow: gallons per day r Alarm present:. ❑ Yes ❑ No Alarm level: Alarm in working order:. ❑. Yes ❑ No Date of.last purnping:_yF b 'Date • - Comments (condition-of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Doral Road Assessor's Map 349 Parcel 33 Property Address Charles W. and Mable J. Holmes Owner Owner's Name information is Barnstable/Cumma uid MA 02637 Aril 30, 2014 required for every q p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Camera inspection showed no adverse conditions. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts r W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 71 Doral Road Assessor's Map,349 Parcel 33 Property Address Charles W. and Mable J. Holmes Owner Owner's Name information is Barnstable/Cummaquid MA 02637 April 30 2014 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: . . leaching pits -number: leaching chambers number; El leaching galleries number: ❑ leaching trenches number, length: El leaching fields ,number, dimensions: overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs-of hydraulic failure,.•level of ponding;damp soil, condition of vegetation, etc.): Soils above leaching pit appear unsaturated. No evidence of surface ponding; breakout, lush vegetation, or other evidence of hydraulic failure was observed. A hole was dug into leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of the leach pit, .Cesspools(cesspool must be pumped as part of inspection) (locate on site,plan): Number and configuration —Depth to of liquid to inlet invert P p q Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts ;H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 71 Doral Road Assessor's Map 349 Parcel 33 Property Address Charles W. and Mable J. Holmes Owner Owner's Name information is required for every Barnstable/Cummaguid MA 02637 April 30, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts' W Title 5 Official Inspection Forml i. s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' 71 Doral Road Assessor's.Map 349 Parcel'33 - Property Address Charles W.and Mable J. Holmes: Owner Owner's Name information a Barnstable/Cummaquid: MA 02637 . Aril 30i 2014 required for every - : p page. City/Town State Zip Code Date of Inspection D. System. Information (cont.)., Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within-.100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately �� . -OF SEPTIC COMPONENTS EMS T§NG DISTANCES IN DECIMAL FEET D WELUNG ;q B'" I - � L 1 :. 32 . 21 A, e: 2, : ; 41 33 n: 3 , 36 38 .. • 1000 GALLON SEPTIC .TANK : LEACH o THIS SKETCH IS PIT p BEST VIEWED IN. a COL OR FORMAT DISTRIBUTION 20 BOX 3 ' m � L�xJllo � ' Z m � " .D.ORAL ..'.. ROAD, 508 .364-0894 t5ins•3/13 -Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 1'5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments QcwM 71 Doral Road Assessor's Map 349 Parcel 33 Property Address Charles W. and Mable J. Holmes Owner Owner's Name information is Barnstable/Cumma uid MA 02637 Aril 30 2014 required for every q p page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 40+ 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: Date 009 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 4.4 feet above the bottom of a witnessed test pit in which no groundwater was encountereded. Town of Barnstable GIS Department records indicate that the property is over 40 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 - 'Commonwealth of Massachusetts" m :.r W Title 5 Official, Inspection Form . Subsurface Sewage Disposal System form,-Not for Voluntary Assessments: , 71 Dora[ Road Assessor's Map 349 Parcel 33 s Property Address .. Charles W. and Mable J. Holmes Owner Owner's Name information is. Barnstable/Cummatiuid MA= 02637: Aril 30 2014 required for every P page. Citylrown state Zip Code ',.Date of Impection E. Report Cormpleteness Checklist ' 3 ,F ti ® inspection Summary:A; B, C, D; or-E checked ® Inspection Summary D (System Failure Critena,Applicable.to All Systems)completed Z. System Information-Estimated depth.to high groundwater - . .® Sketch of Sewage Disposal System either drawn on page 15 or attached In separate file a, f m - GEOHYDROL OGICAL PROFILE.- NOT TO SCALE K _j .. - PRECAST I:EACH �+ W a+ v PIT . BOTT M r a O OF , A E CHING � ` PER DESIGN W s . . .'LEACHING IS ABOVE HIGH GROUNDWATER 3 z NO . .GROUNDWATER +. ENCOUNTERED r a GROUNDWATER ELEVATION . PER GIS .MAPS_ t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17-w ° d _.._ . Town of Barnstable P# / Department of Regulatory Services I MUMa Public Health Division Date-11--2 eJ9. 200 Main Street,Hyannis MA 02601 aala Date Scheduled /� /a/ 7 Time Fee Pd. �U r Soil Suitability Assessment for Sewage Disposal Performed By: ? 11411 S Witnessed By LOCATION&GENERAL INFORMATION location Address Owner's Name CWW�??/✓J�Q V��, �q Address 7/.l�oL �9✓E /�° Cr.La�rn<ld�J Assessor's Map/Parcel Engineer's Name NEW CONSTRU1ONO33 REPAIR" `✓ Telephone# e tand Use Slopes(%) Surface Stones /✓an/ Distances from: Open Water Body G1d` ft Possible Wet Area _rQO ft Drinking Water Well 2-::2i�ft Drainage Way /e>0 ft line . �P�Y .__R. Other SKETCH:(Street name,dimensions of kit,exact locations of test holes&pen:tests,locate wetlands proximity to holes) 11�.,oq4 F . / t : T� ZE V° 2 :. " fV CD CX7 ` rri Parent material(geologic) /10-64-1 Z Depth to Bedrock (fi �: n Depth to Groundwater. Standing Water in Hole: /rl&X Cn1C Weeping ftom Pit Race r nze. Estimated Seasonal High Oroundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used Depth Observed standing in obs.hole: in.- Depth to soil mottles: in. Depth to weeping from aide of obs.hole: in, Groundwater Adjustment fr. Index Well# Reading Date: Index Well level Adj.thetor. Adj.dwirfldwater ILAevg ;y„e PERCOLATION TEST ngte&I 1a� Observation Hole# V Time at 4" Depth of Pere1/a' ` Tlme at 6" Al Start Pre-soak Time Ca Y ,O End Pre-soak M RateMinJlnch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICWERCFORM.DOC L DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. DEEP'OBSERVATION HOLE LOG Hole`#Z Depth from-.', Soil Horizon Soil Texture Soil Color Soil Other Surface(in.)- (USDA) (Munsell) Mottling, ,,(Structure,Stones,Boulders. / Y-3LY �'l4� s L r or DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders. l Flood Insurance Rate May: / Above 500 year flood boundary No_ Yes ✓__ Within 500 year boundary No= Yes Within 10o year flood boundary No— Yes Depth of NaturallY Occurrine Pervious Material Does at least four feet of naturally occurring peprvious material exist in all areas observed throughout the, ed for the soil absorption system?area proposed rP ys . P If not,what is the depth of naturally occurring p material? Certification I certify that on �AonmentalProtectioji (date)I have passed the soil evaluator examination approved by the Department of Envand that the above analysis was performed by me consistent with . the required train' ,e an a hence described in W CMR 15.017. Signatur Date -3 /G D 7 Q:\SF1FMPERCFORM.DOC ASS SSOR'S MAP NO:-g9l"-7fS9PARCEL £ �(� .p L CA ION SEWAGE PERMIT NO. Y I G E ',' INSTALLER'S NAME A ADDRESS M �R U I L D E R 0R 0y DATE PERMIT ISSUED DATE C 0 M P L I A N C E ' ISSUED � ✓-� _ � � � I GcAQ��� 4 J ASSESSORS MAP NO: No---- ................... ...................... THE COMMONWEALTH OF MASSACHUSETTSLA b� BOARD OF HEALTH ,�_ W, 3� ...D ..� ..... 2 dA Allp iration for Di-qVulia1 luorLi Tomitrnrtinn rrmit Application is hereby made for a Permit to Construct (L.,� or Repair ( ) an Individual Sewage Disposal System at: Port ro ��.�-� ¢� ....................... ................_-.........- •;--•••-•----- -• -•...........-------------•••••---•---•••-•---•-----....----••------•----•----------•-••-•-------- Location-Address or Lot No. � T caner 1 _•________________•__-____-...•-Address nstaller Address Type of Building Size Lot_-�,_:5 ........Sq. feet t- Dwelling—No. of Bedrooms______________3 ...........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ------------------------------------•--------- W Design Flow_______________✓r3___.____..._._____._gallons per person per day. Total daily flow...........330......................gallons. WSeptic Tank—Liquid*capacity.�o_.gallons Length_8_X _._ Width. X_ ___ Diameter________________ Depth_................ Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area----------_---------sq. ft. - Seepage Pit No-------/----------- Diameter.____./z.______. Depth below inlet....... .__........ Total leaching area_____.3_3M.�Ls q. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.._:r ..P:.�!9AR ` 2= Date-- iC. Test Pit No. 1_L_?-_____minutes per inch Depth of Test Pit_____ __- Depth to ground water_____"................ Test Pit No. 2...L.Z____minutes per inch Depth of Test Pit....�^�`���____ Depth to ground water.....7................. P ------•----------------------------•--------------------------------------------•---.........-------......................................................... O Description of Soil `.= .. WaoDl / Sep �aSo�...________......'..=-... '- ---....� .......................... U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------------------_......... ______ -•-------•-•-------•--------•---------------•-•------------------------------------._...............• ----•-...----i------••••---•-•••-•------•---••--•-••-•-•-•--•-•--•-----••--••-•-•-•...........•-•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITi:;,.. p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation irtil a Certifica , of m ce has been issued by the boa d of health. �; � - ---- ---- ------ ..................... Application Approved B .. .. ... ..... ...... ........... .................... ? -- Date Application Disapproved for the follow reasons------------------------------------------------------------------------ ---------------------------------------- ------•----•---------------------------------------------------------------------------------•-•••------- -•------------------------------ - Date PermitNo......................................................... Issued....................................................... Date • '�4 No.... _.... ...... . ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - 1/✓I............ OF...-.�J.�J.c'it/j7�i�l.3G-�--------•.................................. Applir.a#ion for MipoiiFal Worko Tomitrartion Famit Application is hereby made for a Permit to Construct (v) or Repair ( ) an Individual Sewage Disposal System at: ................»..--».......................................................................... ...................................................._---.......................................... Location-Address or Lot No. ...... c..?I/ „ wner t Address 04 A ................................L4.1 ----........... .[.�!5..:__:.............•--- ----._....----•--•--------............•--...........--------.._........_-----.:..--------------•• „� Installer •�' Address _ �n 5 /.�o � Type of Building Size Lot___3_____ ........Sq. feet .� Dwelling—No. of Bedrooms............. ___________________________Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons_____________________•__._._ Showers — Cafeteria Q' Other fixtures ...................................................... W Design Flow............... .............................gallons per person per day. Total daily flow________.._3_r�__Q_-______ _.____._____gallons. WSeptic Tank—Liquid capacityfop_gallons Length_!._C_ ___. Width..' &_ .___ Diameter................ Depth_ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......l_........... Diameter------ZZ-------_ Depth below inlet......l........... Total leaching-area__::�:7f_5.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-___ZkA_._�'___ / � _._" _________________ Date._/-I - ;. � Test Pit No. 1_ __ ......minutes per inch Depth of Test Pit_____ ` . Depth to ground water_...____________- Test Pit No. 2__.�_.Z_____minutes per inch Depth of Test Pit.... ___. Depth to ground water...-.................. a+ ---------•--•----•-•-•--•-•-••-------------•-•------------------------------------------------------------------------••-------------------------------__--- O Description of Soil.._©_` 24" WOOD4 �t�r �_Su....:....o{t T�-=f ...... . ....�2 Y,---G�E' - --------- "►� 5/J-iyv--•-------...44. .............----fib ...5E ---- ......ip--•----•--------•---------.•.-------•---------•-------------------------------------•-•------------- W ----------------------------•-----•--•-•--•-•-••-•----•-•----••-•-----------•-----•----....-----••---------•----••--------------...-----•--•----------------------..--------••------••••-•-----•-_------ UNature 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation uptil a Certifi(aI of 0omnliance has been issued by the board of health. e- `� ` fr---- Sig ed. {� ..` Dat Application Approved By......................- --=-Y----- ----= ----------: .....-----...------ ��/1 :�_... Date Application Disapproved for the follow n reasons:--------------------------------------------------------------------------------------------------------------» _--5...............•--•••-----------------------------•••-•-••....••--••.....-•-----------•----•-----------•-•----•--•--•-•-------------•--------•-•-----------•--------•------------ Date PermitNo......................................................... Issued_................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............./..c2•IN ..........-OF...... !..! N.S: .3 ................................. Trr#ifiraU of Toag ph ana THIS IS TO CERTIFY, T thhe� Individual • wage Disposal ystem onstructed or Repaired ( ) b _ �...`��................. �� t R��_e_I� ,_ "! -Y........................•--_. �. �.. Installer at - ------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as d s 'b d in the application for Disposal Works Construction Permit No......................................... d, � d_...-- 7._ �. _ -- ---.----.--.-•.- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT THE SYSTEM WILL FUNCTIONSATISFACTORY. DATE � ....................... Inspector. l ` � _._X•-'.................--- DESIGNING NGINEER MUST SUPERVI 3THE COMMONWEALTH OF MASSACHUSETTSINSTALLATION AND CERTIFY IN WRITIN t BOARD OF HEALTH THE SYSTEM WAS INSTALLED IN STRI ,,.•-�"° ACCORDANCE TL AN. .!.c/��............0 F......... .�,�ns�(-S713 " -'-- '. No... ., FEE........................ i �a �a1 r a i aT rmit y IrPermission is hereby granted......_.......... �__ _L ..--_-__-.----�a _it _ --- -._ !..1 .._.. -/1--1•_-- ...:;..4� ...... to Construct ( ) or Repair ( ) an Individual Sewage�.. lsposal System ' at No........................L!?-�---..I.T:.5_...........b.0 PA...`.......1A....--------.. c.y'�w�'n...-ut.(1,---------------------.._..----•--.........-- Street l� as shown on the application for Disposal Works Construction Permit No..................... Dated_... _�_l ............ •-----•-----------------•-----------------------...................................................... Board of Health DATE.....-.................................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS „, t}�• i Ace � I IZb,2L�G ,moo I i I I J _ /4o wJ Dtr G L' pox 22 ! i k- _/ � E Top oi= P2opos�`b \. \ •� v \ ' ZoT*/1:6- S \ \ \ J 4?/cT got LIP h$ -10 LOCATION .�A'eNST�yBGE� �Cvr�HAQ�/D� SCALE . '40 DATE Jz;Cv 8 /98� PLAN REFERENCE S/oWAI -,A/ T�13 1;- 0_F �>� . . .j. .fLNST/a�L�...�r�nlr�. . . . . .. .. . KELLEY � No. 25103 ,.�.Rr . .. . . . . . . .. .. . . . . . . .. . . . . . . . . . .. . s„ �G Sit�� s, 1 CERTIFY THAT THE ..... ... . .. . .. �• LY. `� %� SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. DATE . .. . ..... . . . .. e~VO-✓ .4EA27y 7704-IS7 — Ae77 T/on/E-72 REGISTERED LAND SURVEYOR TOP OF FOUNDATION s CONCRETE COVER CONCRETE COVERS ¢,ry' •e a 4"CAST IRON 12 MAX. OR SCHEDULE 40 12"MAX. r3/4" P.V.C. PIPE 4„SCHEDULE 40 PVC.(ONLY) -f PIPE- MIN:PITCH I/4"PER. LEACH P ITCH I/4"PER.FTPITINVERT o QEL..�9-¢B. INVERT INVERT o wSEPTIC TANK DIST.INVERT .. . . . BOX...• GAL. INVERT %; L' � 0 INVERT ww : 2' ELGB./o e.' �� �.w ip o. 1 Z I DIA. NONE � T D PROFILE OF GR :�q OUND WATER TABLE SEWAGE DISPOSAL SYSTEM ° - .maySwTRs� NO SCALE gedq ,a /o'BEND P3 " Be' e�,ovE'o ,qr.a - 3 z 12&�q6qc-4-D w,� 34rv,v. SOIL LOG WITNESSED BY : DATE !` ?-�L� ����TIME.cJ'�3o A~J f��LC. C_ Nu�2A� BOARD OF HEALTH TEST HOLE I TEST HOLE 2 ,q ,�: j�/,g �� T,� ELEV. . 74•.79. . . ENGINEER ,727 4;z.7101,zo TEN DESIGN DATA : NUMBER OF BEDROOMS CG3N TOTAL ESTIMATED FLOW 330 GALLONS/DAY j� so BOTTOM LEACHING AREA SQ.FT. /PIT/C.P. L SIDE LEACHING AREA . . . . . c SO.FT./ PIT/.SZ5C.�,P. G7,N Qr DISPOSAL .Non o /o �31ii \���,• So� GARBAGE I . .(50 AREA INCREASE) �z• 5B,7o c LEA TOTAL LEACHING AREA . . 3MP 3. . SQ.FT Q. � HEfD. SAND (�=S 71/9x/ 7Zt/o Cns�� PERCOLATION RATE MIN/INCH 5"7 70 �Z,b� LEACHING AREA PER PERCOLATION RATE .A-?'. SQ.FT`1.P.D. .!!/o. .WATER ENCOUNTERED NUMBER OF LEACHING PITS 0?U6. APPROVED . .. . . . . . . . . BOARD OF HEALTH ' `. ! ZfT„O.� �77�!\/� O•V /UGC. DATE. . . . . . . . . . AGENT OR INSPECTOR �sw OFgs LOTC7 IL PETITIONER Cihv.�on� �7y 7;P-fIS7- EDWARD 'E. KELLEY REG. LAND SURVEYOR CUMMAQUID, MASS. 02637 k TEL : (617 ) 362-2266 Town of Barnstable Oct. 22, 1986 Board of Health 'F Hyannis, Mass. Ref: Canon Realty Trust, Lot # 155 Doral Rd. , Cummaquid, Mass. The sewage system was installed in accordance to the appoved plan. It was installed in existing pervious material, therefore the ten foot excavation was not required. It meets all requirements of Title V and the Town of Barnstable Health regulations. %OF AN 6F 414SS�C EDWARD yes ,d E. R." a KELLEY 26� , N No 7 . eg =fit rian Re fes tonal sANIlAO�ACo e. Vr Land Sur�ve:yor